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Chinese Journal of Traumatology 2014;17(2):108-111

Review

Damage control resuscitation for massive hemorrhage
Osaree Akaraborworn*
【Abstract】Hemorrhage is the second most common
cause of death among trauma patients and almost half of
the deaths occur within 24 hours after arrival. Damage
control resuscitation is a new paradigm for patients with
massive bleeding. It consists of permissive hypotension,
hemostatic resuscitation and transfusion strategies, and
damage control surgery. Permissive hypotension seems
to have better results before the bleeding is controlled.
The strategy of fluid resuscitation is minimizing
crystalloid infusion and increasing early transfusion

H

emorrhage causes about 30% to 40% of
trauma death, which is the second most
common cause of trauma death following
traumatic brain injury. 1,2 Massive blood loss is
usually defined as loss of entire blood volume within
24 hours or loss of 50% of blood volume within 3
hours.
The management of hemorrhagic shock
has evolved over the decades followed by new
development in basic sciences and clinical trial
evidence. Damage control resuscitation (DCR)
is first introduced in military medicine and then is
adapted for civilian trauma to deal with massive
hemorrhage. DCR consists of three main strategies:
permissive hypotension, hemostatic resuscitation
and transfusion strategies, and damage control
surgery. It aims to reduce bleeding and optimize
coagulation3 and is especially beneficial for patients
with massive hemorrhage.4

DOI: 10.3760/cma.j.issn.1008-1275.2014.02.010
Division of Trauma Surgery, Department of Surgery,
Faculty of Medicine, Prince of Songkla University, Hat Yai,
Songkhla 90110, Thailand (Akaraborworn O)
*Corresponding author: Tel: 66-887834121, Fax: 6674429384, Email: aosaree@gmail.com

with a high ratio of fresh frozen plasma to packed red
cells. Damage control surgery is done when the patient’s
condition is unfit for definitive surgery. Hemorrhage and
contamination control with temporary abdominal closure
is performed before transferring the patients to intensive
care unit and the operating room for a permanent
laparotomy.
Key words: Shock; Hemorrhage; Resuscitation
Chin J Traumatol 2014;17(2):108-111

Permissive hypotension
Permissive hypotension is one component of
DCR, which is put forward because higher blood
pressure may displace the clot or “pop the clot.”3 In
practice it requires holding intravenous fluid, and
maintaining a lower blood pressure until hemorrhage
is controlled.3 A landmark article published in 1994
by Bickell et al5 was conducted on 598 hypotensive
patients with penetrated torsos. The result showed
survival advantage in the delayed resuscitation
group which received intravenous fluid resuscitation
after the hemorrhage had been controlled. Patients
in an immediate resuscitation group required longer
hospital stays (14 days vs. 11 days, P=0.006).
However, a systematic review6 published in 2003
showed non-convincing results against early and
large-volume resuscitation.
There is still no consensus on an accepted
blood pressure for permissive hypotension. A study7
used a mean arterial pressure (MAP) of 60 mmHg
as the endpoint of hypotensive resuscitation in
swine. This study showed that increasing MAP to
75 mmHg was associated with high blood loss and
diminished splanchnic blood flow while delayed
fluid resuscitation decreased blood loss but failed to
reestablish splanchnic blood flow. Several studies
conducted on human used a target blood pressure.

5) and low ratio (1:8. 16%.10 An European guideline also recommends a target systolic blood pressure of 80-100 mmHg until bleeding is controlled in patients without traumatic brain injury. Other civilians studies21.19 Many studies demonstrated that a high ratio of fresh frozen plasma (FFP) to packed red cells (PRC) had survival advantage. 9 Systolic blood pressure of 7080 mmHg as a threshold value of resuscitation has also been proposed. The results also showed that the lower blood pressure group had less coagulopathy and lower mortality in the first 24 hours postoperatively.001).18 There is evidence that transfusion of plasma-free red blood cell products is associated . crystalloid. administration of tranexemic acid reduces the risk of mortality (14. and coagulopathy.Chinese Journal of Traumatology 2014. Although this study intended to recruit both blunt and penetrating patients. and found that the group with a target MAP of 50 mmHg had less blood products transfusion when compared with the group with a target MAP of 65 mmHg.24 With resuscitation with high ratios of plasma and platelet to PRC proposed. which ratio is the best for patients needs to be investigated with randomized controlled trials.11 Hemostatic resuscitation and transfusion strategies Hemostatic resuscitation and transfusion strategies aim to minimize coagulopathy. An investigation20 conducted on 246 patients at an army combat support hospital found that patients with a high ratio of FFP:PRC (1:1. abdominal compartment syndrome. Traditionally. 14 Thromboelastography or thromboelastometry are new tools which help to diagnose acute traumatic coagulopathy more quickly15 as well as provide more details than the traditional international normalized ratio.18. 19%. Normal saline and lactated Ringer solution were the most commonly used in resuscitation.22 also found that patients transfused with a high ratio of FFP:PRC had better survival rates than those with a low ratio. 109 . but this recommendation lacks strong evidence. P=0. however. 10 Evidence later revealed that administration of crystalloid during the initial resuscitation was associated with complications such as multi-organ dysfunction.13 probably due to endogenous systemic anticoagulant and hyperfibrinolysis.4) had a lower mortality rate than those receiving intermediate ratio (1:2. However.0035) 16 but requires administration within 3 hours post injury. In patients with hyperfibrinolysis.10. a majority of them suffered a penetrating trauma.and plasmabased resuscitation has replaced whole blood-based resuscitation. Later studies demonstrated that coagulopathy occurred before the patients received massive intravenous fluids. Although the resuscitation with early transfusion with a high ratio of FFP:PRC seems beneficial. coagulopathy in trauma is thought to be a secondary effect from hemodilution after massive fluid resuscitation. it has not been proved by a prospective randomized control trial. A better understanding of the mechanism of coagulopathy makes the paradigm of resuscitation changed accordingly.25-27 In summary.17(2):108-111 Morrison et al 8 investigated patients with blunt and penetrating trauma who had experienced inhospital hypotension. Damage control surgery Damage control surgery is an initial control of hemorrhage and contamination followed by . palpable radial pulse and normal mental status were reported as the endpoint of resuscitation. respectively. resuscitation by minimizing crystalloid infusion has been initiated simultaneously. P<0.17 Since the late 1970s. An ongoing prospective trail (the Pragmatic Randomized Optimum Platelet and Plasma Ratios) is funded by National Institutes of Health and the United States Department of Defense. In military trauma care.12.5% vs. with coagulopathy. A prospective observational study by Holcomb et al23 demonstrated that the patients who received blood transfusions early with high ratio of FFP:PRC had decreased 6-hour mortality even though the subsequent risk of death at day 30 was not associated with ratio of plasma or platelet to PRC. hemostatic resuscitation and transfusion strategies have been moved toward minimizing crystalloid infusion for resuscitation and using a high ratio of blood products. 34% and 65%. those are retrospective studies.

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