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DAMAGE CONTROL RESUSCITATION (DCR)

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1. DEFINITION AND CONCEPT

• Worsen trauma-induced coagulopathy (TIC) by diluting clotting factors
• Cause abdominal compartment syndrome
• Exacerbate hypothermia, acidosis, and inflammation
• Can "pop the clot" by raising hydrostatic pressure at sites of non-compressible hemorrhage

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2. THE LETHAL TRIAD (Bloody Vicious Cycle)

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3. ATLS 11th EDITION (2025) - KEY UPDATES FOR DCR

x-ABCDE Framework

DCR Principles embedded in ATLS 11e:

• Immediate hemorrhage control as the first priority
• Permissive hypotension targeting SBP ~90 mmHg (MAP ~60 mmHg) until surgical hemostasis
• Restrict crystalloids - use blood products from the start
• Early whole blood or balanced component therapy (1:1:1) - pRBC : FFP : platelets
• Tranexamic acid (TXA) - given as early as possible (ideally within 3 hours of injury)
• Avoid over-resuscitation

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4. COMPONENTS OF DCR (Box-by-Box)

A. HEMORRHAGE CONTROL (First Priority)

• External hemorrhage: Tourniquet, wound packing, direct pressure, hemostatic dressings
• Internal hemorrhage: Expedited surgical or interventional radiology (IR) control
• Prehospital DCR has been shown to confer survival benefit (Cannon JW, NEJM 2018)

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B. PERMISSIVE HYPOTENSION

• Traumatic Brain Injury (TBI)
• Blunt trauma with suspected occult hemorrhage in elderly
• Cardiac disease (myocardial ischemia), cerebrovascular disease

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C. RESTRICTIVE CRYSTALLOID USE

• Isotonic crystalloids (NS, LR) are NOT preferred as primary resuscitation fluid in hemorrhagic shock
• Problems with large-volume crystalloid:
  • Only ~25-30% stays intravascular (LR/NS distributes across interstitial space); need 3:1 ratio to replace 1 L blood loss
  • Causes dilutional coagulopathy, hypothermia, hyperchloremic acidosis (NS), and abdominal compartment syndrome
• Current approach: Limit crystalloid; if needed initially, give 250-500 mL aliquots while blood products are prepared
• Transition immediately to a plasma-based Massive Transfusion Protocol (MTP) once ongoing hemorrhage is recognized

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D. BLOOD PRODUCT RESUSCITATION (Hemostatic Resuscitation)

Massive Transfusion

• Defined as >10 units pRBCs in 24 hours (or >3 units in 1 hour in some definitions)
• Affects ~3-5% civilian trauma, ~10% military trauma patients

Predicting Massive Transfusion - ABC Score

• Penetrating mechanism
• Positive FAST
• SBP <90 mmHg
• HR >120 bpm
• Score ≥2 = activate MTP (sensitivity 76-90%, specificity 67-87%)

Blood Product Ratios - 1:1:1

• The PROPPR trial (Holcomb et al., JAMA 2015) confirmed 1:1:1 pRBC:FFP:platelets vs 1:1:2 ratio showed improved 24-hour and 30-day hemostasis and survival benefit
• Improved survival also seen with early high plasma:pRBC ratios (~1:1.4) from combat data
• Use ABO-compatible blood; type O negative pRBC and AB+ FFP for emergencies
• Fresh whole blood is superior (currently mainly military setting); civilian equivalent is 1:1:1 component therapy

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E. CORRECTION OF THE LETHAL TRIAD

1. Hypothermia Prevention and Treatment

• Target temperature: >36°C
• Apply active external warming immediately
• Use warmed IV fluids and blood products (all resuscitation fluids should be warmed)
• Keep patient covered; reduce exposure time

2. Acidosis Correction

• Target: normalize base deficit and lactate
• Serial lactate and base deficit measurements guide adequacy of resuscitation
• Central venous O2 saturation (ScvO2) target: 60-70%
• Tissue O2 saturation (StO2) by near-infrared spectroscopy: maintain >50%
• Acidosis resolves with hemorrhage control and adequate perfusion - not with bicarb

3. Coagulopathy Management

• Use balanced blood products (FFP, cryoprecipitate for fibrinogen replacement)
• Calcium replacement: pRBCs and FFP contain citrate that chelates calcium - administer calcium chloride (preferred over gluconate) to maintain ionized calcium ≥0.9 mmol/L
• Viscoelastic testing (see below)

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F. TRANEXAMIC ACID (TXA)

• Antifibrinolytic agent - blocks plasminogen activation
• CRASH-2 trial (Roberts et al., Lancet 2011): TXA reduced mortality in bleeding trauma patients by ~1.5% absolute risk reduction
• MILITARY DATA (MATTERs study): TXA with MTP reduced mortality (OR 0.46) in combat casualties
• Dosing: 1 g IV over 10 min, then 1 g IV over 8 hours
• Timing: Must be given within 3 hours of injury - after 3 hours, may be harmful (paradoxically increases mortality)
• The ATLS 11th edition emphasizes early TXA as a standard component of DCR
• Ongoing research to identify which specific patient subgroups benefit most

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G. VISCOELASTIC HEMOSTATIC ASSAYS (VHA)

• They are slow (30-45 min turnaround)
• Performed at 37°C (don't reflect hypothermic coagulopathy)
• Don't assess fibrinolysis or platelet function

• Clot formation time (reaction time)
• Clot kinetics (alpha angle)
• Clot strength (maximum amplitude - MA)
• Fibrinolysis

• Prolonged reaction time/clot time - give FFP
• Low MA/amplitude - give platelets or cryoprecipitate
• Fibrinolysis detected - give TXA

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H. ADJUNCT HEMOSTATIC AGENTS

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I. HYPERTONIC SALINE

• 7.5% hypertonic saline can pull water into the vascular space (table below)
• Volume effect: 1 L of 7.5% saline expands plasma by ~990 mL (vs 275 mL for NS)
• Useful as a small-volume resuscitator
• May have immunomodulatory effects
• Use limited by sodium load and risk of hypernatremia

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5. DCR IN CONTEXT: THE THREE PHASES

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6. SUMMARY TABLE - DCR COMPONENTS (from Sabiston Box 33.2 & ATLS 11e)

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7. SPECIAL POPULATIONS

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8. KEY CLINICAL TRIAL REFERENCES

• CRASH-2 (Lancet 2011) - TXA reduces mortality in bleeding trauma within 3 hours (PMID: 20554319)
• PROPPR (Holcomb et al., JAMA 2015) - 1:1:1 vs 1:1:2 pRBC:FFP:Plt; 1:1:1 superior for hemostasis and 24-hr survival
• PAMPer Trial (Sperry et al., NEJM 2018) - Prehospital plasma transfusion improved 30-day survival in blunt trauma hypotensive patients transported by air
• MATTERs - Military TXA with MTP reduced mortality in combat casualties

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KEY TAKEAWAYS

1. DCR = stop bleeding + permissive hypotension + blood products 1:1:1 + TXA + correct lethal triad
2. ATLS 11e (2025): DCR is now core doctrine; x-ABCDE prioritizes exsanguination control before airway
3. TXA must be given within 3 hours - after that it may harm
4. Crystalloids are restricted - they worsen coagulopathy, dilute clotting factors, cause ACS
5. Whole blood is the ideal resuscitation fluid; 1:1:1 component therapy approximates it in civilian practice
6. Permissive hypotension is contraindicated in TBI, elderly, and cardiac/cerebrovascular patients
7. TEG/ROTEM enables real-time, goal-directed hemostatic resuscitation

Recent evidence alert: A 2025 review of ATLS 11th edition updates (PMID: 41671886) confirms DCR integration as a core principle alongside x-ABCDE; no contradictions to the textbook content above.