Damage Control Resuscitation

Abstract

Evidence for changes in adult trauma management often precedes evidence for changes in pediatric trauma management. Many adult trauma centers have adopted damage-control resuscitation management strategies, which target the metabolic syndrome of acidosis, coagulopathy, and hypothermia often found in severe uncontrolled hemorrhage. Two key components of damage-control resuscitation are permissive hypotension, which is a fluid management strategy that targets a subnormal blood pressure, and hemostatic resuscitation, which is a transfusion strategy that targets coagulopathy with early blood product administration. Acceptance of damage-control resuscitation strategies is reflected in recent changes in the American College of Surgeons' Advanced Trauma Life Support curriculum; the most recent edition has decreased its initial fluid recommendation to 1 L from 2 L, and it now recommends early administration of blood products without specifying any specific ratio. These recommendations are not advocating permissive hypotension or hemostatic resuscitation directly but represent an initial step toward limiting fluid resuscitation and using blood products to treat coagulopathy earlier. Evidence for permissive hypotension exists in animal studies and few adult clinical trials. There is no evidence to support permissive hypotension strategies in pediatrics. Evidence for hemostatic resuscitation in adult trauma management is more comprehensive, and there are limited data to support its use in pediatric trauma patients with severe hemorrhage. Additional studies on the management of children with severe uncontrolled hemorrhage are needed.

Hypotensive Resuscitation among Trauma Patients

“…This resuscitation strategy uses limited fluids and blood products during the early stages of treatment for hemorrhagic shock in order to maintain a lower-than-normal blood pressure until operative control of the bleeding can occur. The goal is to limit additional bleeding due to “popping the clot” while still providing oxygen to the tissues [4, 5]. The use of restricted fluids has been shown to improve outcomes in animal models [6]; until recently, few randomized controlled trials on hypotensive resuscitation existed in trauma patients [7–11].…”

Balanced resuscitation: application to the paediatric trauma population

“…Moreover, the mechanisms of civilian paediatric trauma differ from adults. Head trauma and blunt trauma are far more common components of paediatric trauma, both of which are considered contraindications to permissive hypotension [7,15,16]. Therefore, the permissive hypotension recommended in adults is not recommended in paediatric trauma patients if applying a balanced resuscitation approach.…”

Anesthesia and Analgesia In War and Terror Injuries

“…Masif kan transfüzyonu, modern savaş politravma hastasının yönetiminde için çok yönlü yaklaşımın yalnızca bir bileşenidir. Hemostatik re-süsitasyon, permissif hipotansiyon ve masif transfüzyon arasındaki etkileşime odaklanılmalıdır (25,26) . Hemostatik resüsitasyon kanamanın proaktif yöneti-mi olan pıhtılaşma faktörlerinin azlaması, asidoz ve hipotermi ile ortaya çıkan akut travma koagülopa-tisinin etkilerinin önüne geçmektir (26) .…”

“…Hemostatik re-süsitasyon, permissif hipotansiyon ve masif transfüzyon arasındaki etkileşime odaklanılmalıdır (25,26) . Hemostatik resüsitasyon kanamanın proaktif yöneti-mi olan pıhtılaşma faktörlerinin azlaması, asidoz ve hipotermi ile ortaya çıkan akut travma koagülopa-tisinin etkilerinin önüne geçmektir (26) . Hemostatik resüsitasyon, yaralanmanın hemen ardından tıbbi acil müdahale ekibi tarafından başlatılır, cerrahi ve mikrovasküler kanamalar kontrol altına alınıncaya kadar devam eder.…”