Damage control resuscitation: A sensible approach to the exsanguinating surgical patient

BACKGROUND: The current wars in Iraq and Afghanistan have resulted in the highest rates of combat casualties experienced by the U.S. military since the Vietnam conflict. These casualties suffer wounds that have no common civilian equivalent and more frequently require massive transfusion (greater than 10 units of packed red blood cells PRBCs in less than 24 hrs) than civilian injured. DISCUSSION: Military surgeons have found that traditional approaches to resuscitation, particularly in terms of the ratio of blood products to each other and the timing of these products, often fail to effectively treat the coagulopathy that is present on arrival in these casualties. This observation has been concurrently noted in the civilian trauma literature. These experiences have ignited interest in an alternative approach to the resuscitation of these most grievously injured patients. This approach includes the use of permissive hypotension; the prevention and aggressive treatment of hypothermia with both passive and active warming measures; the temporization of acidosis with use of exogenous buffer agents; the immediate use of thawed plasma in ratios approaching 1:1 with PRBCs; the early use of platelets, often given well before 10 units of PRBCs have been transfused; the early use of recombinant Factor VIIa; and, in military settings, the use of fresh whole blood as a primary resuscitation fluid. This strategy has been called "damage control resuscitation" to emphasize its pairing with damage control surgical techniques. SUMMARY: Review of the published support for this strategy reveals that additional trials are needed to study and optimize these techniques.