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

Review

Damage control resuscitation for massive hemorrhage

Osaree Akaraborworn*
AbstractHemorrhage 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

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 patients
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.

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

Morrison et al 8 investigated patients with blunt

and penetrating trauma who had experienced inhospital hypotension, 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. The results also
showed that the lower blood pressure group had
less coagulopathy and lower mortality in the first 24
hours postoperatively. Although this study intended
to recruit both blunt and penetrating patients, a
majority of them suffered a penetrating trauma.
In military trauma care, palpable radial pulse and
normal mental status were reported as the endpoint
of resuscitation. 9 Systolic blood pressure of 7080 mmHg as a threshold value of resuscitation
has also been proposed.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, but this
recommendation lacks strong evidence.11
Hemostatic resuscitation and transfusion
strategies
Hemostatic resuscitation and transfusion
strategies aim to minimize coagulopathy. A better
understanding of the mechanism of coagulopathy
makes the paradigm of resuscitation changed
accordingly.
Traditionally, coagulopathy in trauma is thought
to be a secondary effect from hemodilution
after massive fluid resuscitation. Later studies
demonstrated that coagulopathy occurred before
the patients received massive intravenous fluids,12,13
probably due to endogenous systemic anticoagulant
and hyperfibrinolysis. 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. In patients
with hyperfibrinolysis, administration of tranexemic
acid reduces the risk of mortality (14.5% vs. 16%,
P=0.0035) 16 but requires administration within 3
hours post injury.17
Since the late 1970s, crystalloid- and plasmabased resuscitation has replaced whole blood-based
resuscitation.18 There is evidence that transfusion
of plasma-free red blood cell products is associated

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with coagulopathy.10,19 Many studies demonstrated

that a high ratio of fresh frozen plasma (FFP) to
packed red cells (PRC) had survival advantage. An
investigation20 conducted on 246 patients at an army
combat support hospital found that patients with a
high ratio of FFP:PRC (1:1.4) had a lower mortality
rate than those receiving intermediate ratio (1:2.5)
and low ratio (1:8, 19%, 34% and 65%, respectively,
P<0.001). Other civilians studies21,22 also found that
patients transfused with a high ratio of FFP:PRC
had better survival rates than those with a low
ratio; however, those are retrospective studies.
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.
Although the resuscitation with early transfusion
with a high ratio of FFP:PRC seems beneficial, it
has not been proved by a prospective randomized
control trial. 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.18,24
With resuscitation with high ratios of plasma
and platelet to PRC proposed, resuscitation by
minimizing crystalloid infusion has been initiated
simultaneously. Normal saline and lactated
Ringer solution were the most commonly used
in resuscitation. 10 Evidence later revealed that
administration of crystalloid during the initial
resuscitation was associated with complications
such as multi-organ dysfunction, abdominal
compartment syndrome, and coagulopathy.25-27
In summary, hemostatic resuscitation and
transfusion strategies have been moved toward
minimizing crystalloid infusion for resuscitation and
using a high ratio of blood products. However, which
ratio is the best for patients needs to be investigated
with randomized controlled trials.
Damage control surgery
Damage control surgery is an initial control
of hemorrhage and contamination followed by

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

intraperitoneal packing and rapid closure as well

as resuscitation in the intensive care unit before
transferring patients to the operating room for a
definitive laparotomy. 28 A landmark article was
published in 1993 by Rotondo et al 28 who found
that patients in the damage control group had a
higher survival rate than the permanent laparotomy
group (77% vs. 11%, P<0.02). In the past decades,
the damage control laparotomy has been refined
several times before formation of the current
model. 29 The core concept of the evolution is to
identify the patients who need the damage control
laparotomy. Damage control resuscitation is added
in the process of damage control laparotomy, and
the techniques for abdominal wall closure have
been changed over time. Currently, the indications
for damage control surgery are mainly physiological
changes such as presence of hypothermia, acidosis
and coagulopathy.29,30

2012;43(7):1021-8.
4. Duchesne JC, Kimonis K, Marr AB, et al. Damage
control resuscitation in combination with damage control
laparotomy: a survival advantage [J]. J Trauma 2010;69(1):4652.
5. Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate
versus delayed fluid resuscitation for hypotensive patients with
penetrating torso injuries [J]. N Engl J Med 1994;331(17):11059.
6. Kwan I, Bunn F, Roberts I. Timing and volume of fluid
administration for patients with bleeding [DB/OL]. [201212-21]. http://onlinelibrary.wiley.com/doi/10.1002/14651858.
CD002245/abstract.
7. Varela JE, Cohn SM, Diaz I, et al. Splanchnic perfusion
during delayed, hypotensive, or aggressive fluid resuscitation
from uncontrolled hemorrhage [J]. Shock 2003;20(5):476-80.
8. Morrison CA, Carrick MM, Norman MA, et al.
Hypotensive resuscitation strategy reduces transfusion
requirements and severe postoperative coagulopathy in trauma
patients with hemorrhagic shock: preliminary results of a

Conclusion
DCR is a strategy to resuscitate patients with
massive blood loss. Permissive hypotension is useful
for patients with penetrating trauma. However, it is
still debated in patients with blunt trauma combined
with head injury. In hemostatic resuscitation and
transfusion strategies, hyperfibrinolysis has been
considered more in resuscitation and Tranexemic
acid is recommended in all trauma patients with
significant hemorrhage. Early transfusion with a
high ratio of plasma to PRC and minimization of
crystalloid usage are also recommended. However,
the exact ratio of plasma to PRC needs to be
investigated. Damage control surgery has developed
until a consensus is reached. The future research
will be focused on temporary abdominal closure. For
example, a new technique should be proposed to
increase success rate of fascial closure.

randomized controlled trial [J]. J Trauma 2011;70(3):652-63.

9. Alam HB. Advances in resuscitation strategies [J]. Int J
Surg 2011;9(1):5-12.
10. Kobayashi L, Costantini TW, Coimbra R. Hypovolemic
shock resuscitation [J]. Surg Clin North Am 2012;92(6):140323.
11. Rossaint R, Bouillon B, Cerny V, et al. Management
of bleeding following major trauma: an updated European
guideline [J]. Crit Care 2010;14(2):R52.
12. Floccard B, Rugeri L, Faure A, et al. Early coagulopathy
in trauma patients: an on-scene and hospital admission study [J].
Injury 2012;43(1):26-32.
13. Carroll RC, Craft RM, Langdon RJ, et al.
Early evaluation of acute traumatic coagulopathy by
thrombelastography [J]. Transl Res 2009;154(1):34-9.
14. Frith D, Davenport R, Brohi K. Acute traumatic
coagulopathy [J]. Curr Opin Anaesthesiol 2012;25(2):229-34.
15. Davenport R, Manson J, DeAth H, et al. Functional
definition and characterisation of acute traumatic coagulopathy

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(Received October 8, 2013)

Edited by Dong Min