Damage Control Resuscitation (DCR) in Trauma

Damage Control Resuscitation (DCR) is a strategic approach to managing trauma patients with severe hemorrhage, aiming to prevent the lethal triad (hypothermia, acidosis, and coagulopathy). It involves early hemorrhage control, permissive hypotension, hemostatic resuscitation, and damage control surgery (DCS) to optimize survival.

I. Principles of Damage Control Resuscitation

1. Permissive Hypotension – Maintaining a lower-than-normal blood pressure to minimize bleeding.

2. Hemostatic Resuscitation – Early use of blood products to correct coagulopathy.

3. Damage Control Surgery (DCS) – Quick surgical intervention to control bleeding and contamination.

4. Avoidance of the Lethal Triad – Hypothermia, acidosis, and coagulopathy must be prevented.

Four Phases of Damage Control Resuscitation (DCR)

II. Key Components of DCR

1. Permissive Hypotension

Volume Resuscitation Guidelines:

• Until major bleeding is controlled, fluid resuscitation should be titrated to maintain:
• Palpable central pulses
• Systolic BP: 80–90 mmHg
• MAP: 50–60 mmHg
• Diastolic BP: 25–35 mmHg (to ensure coronary perfusion)
• Elderly patients may require higher systolic pressure for adequate perfusion.

Traumatic Brain Injury (TBI) Considerations:

• Maintain SBP > 110 mmHg and MAP ≥ 80 mmHg to ensure cerebral perfusion.

Fluids & Coagulopathy:

• Avoid excessive crystalloids, as they can lead to:
• Dilutional coagulopathy
• Tissue edema, worsening clinical outcomes

2. Hemostatic Resuscitation

Vascular Access Considerations:

• Avoid insertion distal to hemorrhage sources, e.g., avoid femoral vein access in abdominal trauma.

Blood Product Transfusion:

• Maintain PRBC: FFP: Platelets in a 1:1:1 ratio.
• Avoid excessive crystalloid infusion (>1.5L) to prevent dilutional coagulopathy.

Tranexamic Acid (TXA) Usage:

• Early administration within 3 hours of injury to counteract hyperfibrinolysis.
• Dosage:
• Adults: 1g IV over 10 minutes, followed by 1g over the next 8 hours.
• Children: 15mg/kg IV over 10 minutes.

Calcium Replacement:

• Calcium chloride 10%: 10mL after every 4 units of PRBCs, or if ionized calcium ≤1.0 mmol/L, to manage hypocalcemia from citrate chelation.

Fibrinogen Correction:

• If fibrinogen <1.5 g/L, administer cryoprecipitate or fibrinogen concentrate.

Hemoglobin & Platelet Targets:

• Hb target: 70–100 g/L.
• Platelet count >50 × 10⁹/L.
• Do not wait for Hb to drop before initiating transfusion, as catching up may become difficult.

Fluids & Coagulopathy Prevention:

• Avoid crystalloids & colloids, except when no other options are available.
• Use small boluses (e.g., 250mL) if required.

Damage Control Surgery (DCS)

Typical DCS Procedures:

• Resuscitative laparotomy,Resuscitative thoracotomy
• Pelvic packing,Junctional surgery (neck, groins, axillae)
• External fixation of fractures
• Multi-team simultaneous surgery possible

Key Principles of DCS:

1. Hemorrhage Control:
• Use packing, vessel ligation, suturing, organ excision (e.g., splenectomy, nephrectomy, lung resection)
• Utilize shunts & hemostatic adjuncts

2. Contamination Control:

• Debridement & removal of contaminants
• Closure of bowel injuries:
• Small injuries: Simple suturing
• Large injuries: Stapling with discontinuous bowel ends

3. Protecting the Patient from Further Injury
4. Temporary Closure for Rapid Control:

• Stop ongoing hemorrhage & contamination with:
• Packing
• Temporary vascular shunts
• Ligation
• No definitive repair during the first surgery
• DCS duration: <60–90 min

Indications for DCS:

• No single threshold—based on a global assessment of the patient’s physiological status
• Consider DCS when surgical bleeding exceeds the patient’s compensatory capacity

Signs of Physiological Exhaustion:

• Severe injury mechanism (e.g., penetrating trauma, high-energy blunt trauma)
• Metabolic compromise:
• pH < 7.25
• Base excess < –6
• Lactate > 2.5
• Massive transfusion requirement (>10 units PRBCs)
• Coagulopathy (lab/POCT results or clinical evidence)
• Hypothermia (<34.0–35.0°C)

Damage control anaesthesia

Double-Lumen Tubes (DLTs): Not recommended, even for thoracic cases, due to added complexity and unfamiliarity for most anesthetists in critical situations.

• Alternative: Use a bronchial blocker or advance a single-lumen tube endobronchially if needed.

Ventilation Strategy (initial phase):

• Limit intrathoracic pressure to prevent worsening circulatory shock.
• Suggested parameters:
• FiO2: 100%
• Respiratory rate (RR): 10 breaths/min
• Tidal volume (VT): 5–6 mL/kg
• PEEP: 0–4 cmH2O (to maintain oxygenation)
• Adjust as volume expands:
• Increase minute ventilation and PEEP
• Gradually reduce FiO2 to normal levels

Maintenance of Anesthesia:

• Volatile anesthesia preferred over TIVA to avoid frequent syringe changes.
• Target MAC: 0.4–0.6
• Fentanyl boluses (50 mcg each, total 2–3 mg per case) for hemodynamic stability and mild vasodilation, aiding fluid replacement and lactate clearance.
• Large fentanyl doses may cause hemodynamic instability.
• Additional ketamine and paracetamol can be administered as needed.

Intraoperative Problems & Considerations:

• Unexplained ↓BP and ↑HR → Suspect hypovolemia, pneumothorax, pericardial tamponade, or retroperitoneal vessel injury.
• Unexplained hypoxia & increased inflation pressures → Consider tension pneumothorax.
• Unexplained ↑BP → Consider:
• Pain
• Increased ICP (look for neurological signs)
• Traumatic aortic disruption (pseudocoarctation effect).

Stages II and III: restoration of normality and

definitive repair

ICU Management Goals:

• Reverse physiological and biochemical effects of injury and hypotension.
• Utilize invasive monitoring and point-of-care testing (POCT) to optimize blood flow.
• Correct coagulopathy and actively rewarm the patient.

Tertiary Survey & Imaging:

• Conduct tertiary assessment to identify missed injuries.
• If the patient is stable post-surgery, a CT scan can be done en route to ICU.

Restoration of Normal Physiology:

• May take up to 48 hours, though some recover sooner.
• Unplanned return to surgery may be needed for:
• Bleeding management
• Shunt occlusion
• Abdominal compartment syndrome

Definitive Surgical Repair:

• Often requires multiple surgeries, especially in polytrauma cases.
• Best performed 48–72 hours post-injury, once the patient is:
• Normothermic
• Hemodynamically stable
• With corrected clotting
• Surgeries should be well-planned, involving specialist teams.
• Multi-specialty teams can operate simultaneously for efficiency.
• Major trauma patients remain physiologically fragile at 48–72 hours, so prolonged surgeries should be stagedto prevent deterioration.
• Anticipate and prepare for blood and fluid losses.
• Use invasive monitoring, frequent POCT, and correction with blood, fluids, and inotropes as required.

Acute Lung Injury (ALI) & Hypoxia Risk:

• Trauma patients are high risk for ALI due to:
• Direct pulmonary contusion
• Fat embolism (common in orthopedic trauma)
• Management includes:
• Lung-protective ventilation
• Advanced ventilatory modes to maintain optimal oxygenation