Damage Control Resuscitation

Abstract

Damage control resuscitation (DCR) is a strategy for resuscitating patients from hemorrhagic shock to rapidly restore homeostasis. Efforts are focused on blood product transfusion with whole blood or component therapy closely approximating whole blood, limited use of crystalloid to avoid dilutional coagulopathy, hypotensive resuscitation until bleeding control is achieved, empiric use of tranexamic acid, prevention of acidosis and hypothermia, and rapid definitive surgical control of bleeding. Patients receiving uncrossmatched Type O blood in the emergency department and later receiving cumulative transfusions of 10 or more red blood cell units in the initial 24-hour post-injury (massive transfusion) are widely recognized as being at increased risk of morbidity and mortality due to exsanguination. Ideally, these patients should be rapidly identified, however anticipating transfusion needs is challenging. Useful indicators of massive transfusion reviewed in this guideline include: systolic blood pressure <110 mmHg, heart rate > 105 bpm, hematocrit <32%, pH < 7.25, injury pattern (above-the-knee traumatic amputation especially if pelvic injury is present, multi-amputation, clinically obvious penetrating injury to chest or abdomen), >2 regions positive on Focused Assessment with Sonography for Trauma (FAST) scan, lactate concentration on admission >2.5, admission international normalized ratio ≥1.2-1.4, near infrared spectroscopy-derived StO2 < 75% (in practice, rarely available), BD > 6 meq/L. Unique aspects of out-of-hospital DCR (point of injury, en-route, and remote DCR) and in-hospital (Medical Treatment Facilities: Role 2b/Forward surgical teams - role 3/ combat support hospitals) are reviewed in this guideline, along with pediatric considerations.

Development of prehospital assessment findings associated with massive transfusion

“…Hemorrhage is the leading cause of potentially survivable death in US military combat casualties. Blood transfusions are frequently administered during the resuscitation of severely wounded combat casualties, especially within the first 6 to 12 hours, when death from hemorrhage is most likely to occur . One definition of massive transfusion is 10 or more units of red blood cells (RBCs) or whole blood (WB) within the first 24 hours of admission .…”

Making whole blood for trauma available (again): the American Red Cross experience

“…For those who indicated a preference for massive transfusion packs, most indicated a preference for either 100 (22%), the lowest titer suggested, or that titer was not applicable. It is possible that among those respondents who favor WB, higher titer cutoffs are acceptable because they are more comfortable with these titers based on the published experience of existing WB users …”

“…It is possible that among those respondents who favor WB, higher titer cutoffs are acceptable because they are more comfortable with these titers based on the published experience of existing WB users. 25 Respondents to the survey were also asked to consider specific bleeding situations and patient types where they would consider using WB for hemorrhage control. Some of these included other situations where significant bleeding could occur outside of trauma and different locations for prehospital administration of blood.…”

“…Interestingly, of the 10 respondents from pediatric trauma programs, the TM physicians overwhelmingly (9 of 10 [90%]) stated that they would not use WB for pediatric resuscitation, citing lack of sufficient published evidence. There are no prospective studies of transfusion resuscitation in pediatric trauma 25 and very limited data showing the safety of LTOWB in children in the setting of hemorrhagic shock. 26 The survey responses we received suggested that most TM physicians were not ready to extrapolate from the larger adult literature with respect to use of WB in trauma for this population.…”

The History of Fluid Resuscitation for Bleeding

“…In 2017, the US Army began transfusing apheresis platelet units stored at 4 °C based on its superior hemostatic function compared to platelets stored at 22 °C [68,69]. The storage duration for the 4 °C platelets started at 3 days with the plan to extend it over time after collecting data.…”