Damage Control Resuscitation

Damage control resuscitation (DCR) for trauma, initially described to address the entire lethal triad (hypothermia, acidosis and coagulopathy) immediately upon admission to a combat hospital before damage control surgery (DCS), is now accepted as part of an integrated approach DCR-DCS from point of wounding to definitive treatment. Therefore, DCR can be divided in two steps: while bleeding is ongoing and once bleeding has been stopped.ATLS ABCDE protocol addresses main components of DCR (permissive hypotension, early plasma administration…). European guideline on management of major bleeding accepts transient use of vasopressors in case of life-threatening hypotension. Red blood cells not only carry and deliver oxygen to tissues but also play a major role in haemostasis; the Hb threshold for RBC transfusion is set to 7-9 g/dL. The fibrinolysis is an essential part of the acute coagulopathy of trauma and can be lowered by early tranexamic acid administration. The replacement of shed, consumed, diluted or inactivated coagulation factors and platelets is crucial to restore haemostasis. Lyophilized plasma or PCC are an alternative to fresh frozen plasma. Fibrinogen, a key component in the coagulation cascade can be administered through cryoprecipitate or fibrinogen concentrate. Viscoelastic techniques allow early diagnosis of coagulopathy and appropriate action.Once bleeding has been stopped, physiology is restored in intensive care unit. Sequelae of hypotension-related metabolic failure are reversed and coagulopathy is aggressively corrected as well as hypothermia. With the aim to restore adequate perfusion of organs, mean arterial blood pressure is targeted to 65 mmHg. The second look operation is scheduled when the lethal triad is under control. “Unplanned” reoperation can be decided because of ongoing surgical bleeding, missed visceral injury or development of an abdominal compartment syndrome.The treatment of bleeding remains to stop the bleeding. DCR is together with DCS part of a global DC strategy. DCR is a potent tool to hinder and even reverse the lethal triad. Delaying bleeding control under the pretext that DCR is available and effective is a fallacious conduct that results in increased morbidity and mortality.