Damage control resuscitation

Abstract

The United States Navy originally utilized the concept of damage control to describe the process of prioritizing the critical repairs needed to return a ship safely to shore during a maritime emergency. To pursue a completed repair would detract from the goal of saving the ship. This concept of damage control management in crisis is well suited to the care of the critically ill trauma patient, and has evolved into the standard of care. Damage control resuscitation is not one technique, but, rather, a group of strategies which address the lethal triad of coagulopathy, acidosis, and hypothermia. In this article, we describe this approach to trauma resuscitation and the supporting evidence base.

Traumatic Brain Injury—A Review of Intravenous Fluid Therapy

“…However, crystalloids lack any pro-survival properties (12) and there is no survival benefit associated with aggressive crystalloid resuscitation in bleeding patients (13,14). Modern damage control resuscitation guidelines for hemorrhaging patients recommend avoidance of crystalloid fluids in favor of early initiation of a 1:1:1 ratio-based transfusion strategy using packed red blood cells, plasma, and platelets (15). This strategy may mitigate hemodilution, hemostatic derangements, brain edema, and inflammation associated with large volume crystalloid infusion and worsening of uncontrolled hemorrhage (9,(15)(16)(17).…”

“…Modern damage control resuscitation guidelines for hemorrhaging patients recommend avoidance of crystalloid fluids in favor of early initiation of a 1:1:1 ratio-based transfusion strategy using packed red blood cells, plasma, and platelets (15). This strategy may mitigate hemodilution, hemostatic derangements, brain edema, and inflammation associated with large volume crystalloid infusion and worsening of uncontrolled hemorrhage (9,(15)(16)(17). In a pig model of TBI and uncontrolled hemorrhage, 100% of pigs died in less than one hour when aggressively resuscitated with isotonic crystalloid solution to a MAP of 80 mmHg, while 50% of pigs that were allowed to remain hypotensive with no resuscitation for one hour survived and went on to have cerebral blood flow return to normal in the second hour following surgical hemostasis and resuscitation with shed blood (18).…”

“…In a pig model of TBI and uncontrolled hemorrhage, 100% of pigs died in less than one hour when aggressively resuscitated with isotonic crystalloid solution to a MAP of 80 mmHg, while 50% of pigs that were allowed to remain hypotensive with no resuscitation for one hour survived and went on to have cerebral blood flow return to normal in the second hour following surgical hemostasis and resuscitation with shed blood (18). Hypotensive resuscitation during damage control resuscitation is contraindicated in people with TBI, where resuscitation to a systolic BP of 90-110 mmHg with limited crystalloid infusion is recommended (15).…”

“…The fluid administration and shock management technique might also matter, particularly in patients with uncontrolled hemorrhage. Current BTF (8) and damage control resuscitation guidelines (15) recommend strongly against hypotensive resuscitation in favor of resuscitation to a systolic BP 90-110 mmHg. There is evidence that even transient episodes of hypotension lead to irreversible secondary brain damage in a time-and dose-dependent manner (66)(67)(68).…”

Trauma Update

“…Damage control resuscitation, currently recommended for actively bleeding patients with major trauma, has been shown to improve patient outcomes. 6 While trauma patients are in the intensive care unit, the advanced practice nurse and other nurses work in collaboration with the rest of the health care team to provide damage control resuscitation, monitor end points of resuscitation, and institute a multitude of interventions to prevent, promptly recognize, and treat onset of multisystem complications. Gaasch's article in this symposium series discusses damage control resuscitation and management of potential complications that can occur in the critical care phase of treating trauma patients.…”