Damage control resuscitation: a paradigm shift in the management of haemorrhagic shock.

Many advances in trauma care have resulted from the treatment of battle casualties by combat medics, military physicians and nurses. A recent example is damage control resuscitation (DCR), which is transforming the care of soldiers with haemorrhagic shock requiring damage control surgery (DCS) in the current conflicts in Iraq and Afghanistan. We believe that these new treatments have application in patients with haemorrhagic shock requiring damage control interventions in the civilian setting and that health professionals in the Australian trauma community should become familiar with these concepts. Exsanguination is the second cause of death after traumatic brain injury in trauma, with massive transfusion required in up to 6% of military and up to 2% of civilian trauma. Coagulopathy commonly occurs during the resuscitation of exsanguinating trauma patients and, with acidosis and hypothermia, comprise the ‘lethal triad’. Coagulopathy increases the risk of preventable death in trauma patients. By directly addressing the ‘lethal triad’, DCR supports DCS. DCR restores intravascular volume and composition, supports depleted circulatory and haemostatic reserve and aims to prevent and treat complications, including acidosis and coagulopathic bleeding in exsanguinating trauma patients. Standard practice for the resuscitation of patients with haemorrhagic shock in Australia and New Zealand is the administration of crystalloid or colloid followed by stored packed red blood cells (PRBC), either crossmatched or group O-negative. Administration of fresh frozen plasma (FFP) and platelets is generally withheld until there is laboratory evidence of coagulopathy or deficiency. However, these exsanguinating patients will usually have clinical evidence of coagulopathy on presentation that requires immediate correction. Borgman et al. demonstrated outcome benefit for patients requiring massive transfusion in a military setting who had administration of a high plasma to RBC ratio (1:1.4). Early plasma administration is now endorsed by the US Army Surgeon General in trauma patients requiring or at risk of massive transfusion. Following prehospital measures to control bleeding, minimal fluid resuscitation and rapid transport to the trauma centre, DCR combines multiple aspects of haemostatic support commencing in the emergency room, continuing during DCS and into the postoperative phase and intensive care unit. DCR is indicated in patients with severe (class IV) haemorrhagic shock (Table 1) who require massive transfusion and immediate DCS. DCR consists of urgent resuscitation to maintain essential circulating blood volume, to preserve life and vital organ function, while preventing and treating coagulopathic bleeding complications in exsanguinating trauma patients. DCR predicts and attempts to correct the physiological disturbances of