Intended for healthcare professionals

Clinical Review

Damage control resuscitation for patients with major trauma

BMJ 2009; 338 doi: (Published 05 June 2009) Cite this as: BMJ 2009;338:b1778
  1. Jan O Jansen, consultant surgeon1,
  2. Rhys Thomas, consultant anaesthetist1,
  3. Malcolm A Loudon, consultant surgeon2,
  4. Adam Brooks, senior lecturer in military surgery and trauma3
  1. 116 Medical Regiment, Royal Army Medical Corps
  2. 2306 Hospital Support Medical Regiment, Royal Army Medical Corps
  3. 3Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Royal Army Medical Corps
  1. J Jansen, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN jan.jansen{at}

    Summary points

    • Trauma resuscitation must address all three components of the “lethal triad”: coagulopathy; acidosis; and hypothermia

    • Damage control resuscitation integrates permissive hypotension, haemostatic resuscitation, and damage control surgery

    • Coagulopathy is common in patients with haemorrhagic shock

    • In trauma patients predicted to require massive transfusion, administration of fresh frozen plasma, packed red blood cells, and platelets in a 1:1:1 ratio (of individual units) is associated with improved survival

    • Recombinant factor VIIa, cryoprecipitate, and tranexamic acid can be considered adjunctive treatments for coagulopathy

    • Damage control surgery is a surgical strategy aimed at restoring normal physiology rather than anatomical integrity; however, this component of damage control resuscitation should not be applied in isolation

    Military conflict has always driven innovation and technical advances in medicine and surgery. Accepted concepts of trauma resuscitation and surgery have been challenged in the wars in Iraq and Afghanistan, and novel approaches have been developed to address the current complexity and severity of military trauma.1 A number of these new strategies have evolved into a single seamless approach that extends from the point of wounding to surgery, and on to critical care. Although the precise contribution of medical care is difficult to ascertain, better trauma management has almost certainly contributed to a remarkable reduction in the lethality of war wounds. Only 10% of United States servicemen wounded in Iraq and Afghanistan between 2003 and 2009 died, compared with 24% in the first Gulf War (1990-1991) and Vietnam War (1961-1973).w1 Initially derived from clinical experience, new concepts in caring for the injured have been refined with experiment and study and have been translated back to the battlefield in a dynamic process.2 Many of these advances are also relevant to trauma care in civilian practice. The aim of this article is to provide an overview of a new approach …

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