Ben Edwards14th March 2014

Damage Control Resuscitation

Term used to describe key concepts

Permissive hypotension

Haemostatic resuscitation

Damage control surgery (DCS)

Jansen J et al. Damage control resuscitation for patients with major trauma. BMJ 2009;338:b1778

“A strategy of deferring or restricting fluid administration until haemorrhage is controlled, while accepting a limited period of suboptimum end organ perfusion”

Aim for Systolic BP 70-80

Recommend use for up to 60 minutes Aim to get control of bleeding within this

time

Should not be used in those with isolated/concurrent head injuries Aim Systolic BP>90 “Normotension”

Therefore most applicable to penetrating trauma BUT 40% polytrauma patients have traumatic

brain injury! Other terminology

Hypotensive resuscitationDelayed resuscitation

Randomised 2 groups with penetrating trauma and BP <90 Immediate Delayed

BP raised to >100 post anaesthesia

Bickell WH et al, NEJM 1994; 331:1105-9Bickell WH et al, NEJM 1994; 331:1105-9

Statistically significant findings: Survival higher in delayed group Stay shorter in delayed group

Trend towards Higher intra-op blood loss in the

immediate group ? More complications in immediate group

Not statistically significant

Bickell WH et al, NEJM 1994; 331:1105-9Bickell WH et al, NEJM 1994; 331:1105-9

Outcome of Patients with Penetrating Torso Injuries, According to Treatment Group

Early use of blood and blood products as primary resuscitation fluids

Trauma induced coagulopathy causes• mortality• incidence of multi organ failure

• Renal • Acute lung injury

• ICU length of stay

Damage control resuscitation: Correct coagulopathy Limit duration of shock Reduce haemodilution

Use high ratio blood component therapy Limit use of crystalloids

Reduce hypothermia Tranexamic acid Factor VIIa

role remains unproven

Each hospital should have oneSTH massive transfusion pack

4 units packed red cells 3 bags FFP 2 bags cryoprecipitate 1 adult dose platelets

Give empirically Use clinical judgement, don’t wait for the

clotting result

Holcomb J et al. Annals of Surgery 2008;248:477-458 Holcomb J et al. Annals of Surgery 2008;248:477-458

Increased Plasma and Platelet to Red Blood Cell Ratios Improves Outcome in 466 Massively Transfused Civilian Trauma Patients

Increased number of coagulation products in relationship to red blood cell products transfused improves mortality in trauma patients

Shaz BH et al. Transfusion 2010;50:493-500Shaz BH et al. Transfusion 2010;50:493-500

Over 20,000 patients ‘with or at risk of significant bleeding’

1g of Tranexamic acid over 10 minutes followed by a further 1 g over 8 hours reduced all cause mortality and deaths due to bleeding

Further analysis showed that must be given within 3 hours of injury

Independent standard for achieving best practice tariff (BPT) payment

“Temporary sacrifice of anatomy to preserve vital physiology”

Do only what is needed to stabilise and address life threatening injuries

Major surgery worsens the immune hit from trauma

DCS only if Temp <35°C INR >1.5 Platelets <120 BE> -5 pH <7.25

Critical care for further resuscitation

Serum lactate useful to assess adequacy of resuscitation

Damage control resuscitation practices are in evolution As studies and evidence develop guidance

will change Military principles applied to a civilian

population Hybrid approach probably the future

Permissive hypotension, haemostatic resuscitation, DCS

Attention to detail vital