Overview
Definition:
Damage control resuscitation (DCR) is a strategy employed in severely injured patients with ongoing hemorrhage, aiming to rapidly correct physiological derangements and achieve hemostasis
It involves a series of interventions focused on stopping bleeding, restoring circulating volume, and correcting coagulopathy, acidosis, and hypothermia.
Epidemiology:
DCR is indicated in patients with severe trauma, particularly those with significant hemorrhage, shock, and coagulopathy
Incidence varies with trauma center volume and patient population but is a critical skill for managing life-threatening bleeding.
Clinical Significance:
DCR is paramount in preventing the lethal triad of trauma: hypothermia, acidosis, and coagulopathy
Early and appropriate application can significantly reduce mortality in severely injured patients, allowing for definitive surgical correction once physiological parameters are stabilized.
Indications
Patient Profile:
Patients with penetrating or blunt trauma presenting with uncontrolled hemorrhage
Signs of hypoperfusion such as hypotension (SBP < 90 mmHg), tachycardia (>120 bpm), and altered mental status.
Laboratory Findings:
Laboratory evidence of coagulopathy (e.g., INR > 1.5, aPTT prolonged, fibrinogen < 1.5 g/L), metabolic acidosis (pH < 7.25), and hypothermia (core temperature < 35°C).
Imaging Findings:
Initial imaging (FAST, CT scan) revealing active bleeding or injuries requiring immediate surgical intervention to control hemorrhage.
Management
Initial Resuscitation:
Rapid infusion of crystalloids (e.g., Lactated Ringer's) to restore permissive hypotension (target SBP 80-90 mmHg) in hemorrhagic shock
Avoid excessive fluid administration to prevent hemodilution and worsening coagulopathy.
Blood Product Administration:
Early and aggressive transfusion of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets in a balanced ratio, typically 1:1:1 (PRBC:FFP:Platelets)
Target hemoglobin > 7 g/dL, INR < 1.5, fibrinogen > 2 g/L, and platelet count > 50,000/µL.
Correction Of Coagulopathy:
Administer fibrinogen concentrate if fibrinogen is < 1.5 g/L, and cryoprecipitate if needed
Consider prothrombin complex concentrate (PCC) or recombinant activated factor VIIa (rFVIIa) in refractory bleeding, with caution due to thrombotic risks.
Correction Of Acidosis And Hypothermia:
Address acidosis through adequate oxygenation, ventilation, and resuscitation
Rewarm the patient using external warming devices and warmed fluids
Avoid delaying surgery due to hypothermia
it can be corrected in the OR.
Surgical Intervention:
Rapid transfer to the operating room for damage control surgery
Focus on temporizing measures to control hemorrhage (e.g., packing, ligation, vascular shunts) rather than extensive reconstruction
Reassessment and definitive management occur in subsequent stages.
Damage Control Surgery
Abdominal Trauma:
Exploratory laparotomy with abdominal packing, ligation of bleeding vessels, application of vascular shunts, and leaving the abdomen open (under temporary closure) to allow for re-exploration and management of edema and coagulopathy.
Thoracic Trauma:
Emergent thoracotomy to control intrathoracic hemorrhage, including pulmonary artery/vein ligation, packing, and placement of chest tubes
Management of the thoracic cavity may also involve temporary closure.
Pelvic Trauma:
External fixation of pelvic fractures, application of pelvic binders, and internal packing for massive pelvic hemorrhage
Interventional radiology (embolization) may also be considered.
Reassessment And Definitive Care
Second Look Operation:
Return to the operating room within 24-48 hours for re-assessment, removal of packing, definitive bleeding control, and repair of injuries once physiological parameters have improved and coagulopathy is corrected.
Intensive Care Unit Management:
Close monitoring of hemodynamics, ventilation, and coagulation parameters in the ICU
Gradual weaning from mechanical ventilation and support for organ function.
Complications
Early Complications:
Persistent hemorrhage, worsening coagulopathy, organ hypoperfusion leading to acute kidney injury, ARDS, and multi-organ dysfunction syndrome
Risks associated with massive transfusion (TRALI, hyperkalemia, hypocalcemia).
Late Complications:
Incisional hernias, abdominal wall defects, adherence syndrome, post-traumatic stress disorder, and chronic pain
Late-onset organ dysfunction.
Prevention Strategies:
Adherence to DCR protocols, timely blood product transfusion, vigilant monitoring, early surgical intervention, and prompt correction of hypothermia, acidosis, and coagulopathy are crucial for minimizing complications.
Key Points
Exam Focus:
Understand the "lethal triad" (hypothermia, acidosis, coagulopathy) and how DCR addresses each
Key ratios for blood product transfusion (1:1:1)
Permissive hypotension target
Indications for damage control surgery.
Clinical Pearls:
Do not delay definitive surgical control for lengthy resuscitation efforts
initiate DCR and surgical intervention concurrently
Recognize that hypothermia can mask coagulopathy
Aggressive early fluid resuscitation with crystalloids can be detrimental in ongoing hemorrhage.
Common Mistakes:
Over-resuscitation with crystalloids leading to hemodilution and coagulopathy
Delayed administration of blood products, especially FFP and platelets
Failure to recognize and aggressively treat hypothermia and acidosis
Inadequate surgical control of bleeding sources.