Damage Control Resuscitation

Abstract

Treatment of active hemorrhage, hemorrhagic shock, and prevention of re-bleeding is the name of your game in combat trauma. There are two big killers on the battlefield: severe brain injury and hemorrhage. You can’t do a lot about the former, but through preparation and attention to detail, you can significantly impact the latter. Assume every injured patient you receive has active bleeding until proven otherwise and make sure that is how they are treated from the moment injury occurs. Be familiar with all the tools at your disposal to guide resuscitation and stop the bleeding. Look at your watch when the patient arrives and keep that ticking clock in mind during your initial trauma evaluation and resuscitation. The whole philosophy of damage control resuscitation (DCR) can be summarized by the observation that “Patients bleed warm whole blood, not just red cells. Therefore, we should replace this with warm whole blood or the equivalent, not cold and coagulopathic packed red blood cells, starting from minute one of the resuscitation.”

Civilian Translation of Military Experience and Lessons Learned

• Donald H. Jenkins 

Key Similarities

• Hemorrhage is among the leading causes of trauma-related mortality and a primary point where preparation and early intervention can improve outcomes.

• DCR principles must start in the pre-hospital setting with a well-developed system for providing RDCR.

• Resource availability provides a challenge to RDCR and DCR care.

Key Differences

• Care of civilian trauma patients is commonly complicated by significant medical comorbidities and pre-injury medication regimens, especially anticoagulants.

• Walking blood banks for FWB administration in emergent situations are essentially nonexistent in civilian hospitals, increasing reliance on component-based resuscitation and ratios.

Lessons learned during times of war have historically been major drivers in the advances in civilian medical care. When the National Academy of Sciences released “Accidental Death and Disability: The Neglected Disease of Modern Society” in 1966, now commonly referred to as the “White Paper,” the hard look at the inadequacy of pre-hospital and early care of the trauma patient in the USA became all the more apparent. Experts at the time who had served in Korea and Vietnam asserted that if seriously wounded, odds of survival were better in the combat zone than on the average city street at that time. Much of this difference was attributed to the “excellence of initial first aid, efficiency of transportation, and energetic treatment of military casualties” [21]. Though we have made great strides in improving care of the injured patient, these areas, identified in 1966, remain as points where we are still working.

Initial first aid as provided in the setting of trauma focuses on control of bleeding. While military service provides a predefined audience of servicemen and women to whom training can be provided in the use of hemostatic gauze and tourniquets, training to the general civilian population is much more difficult. Despite military findings that tourniquets were efficacious with little training while offering little risk to the casualty, adoption in the civilian setting has been much slower. Reasons for this slower adoption may be from concern for patient harm when tourniquets are applied incorrectly by untrained emergency medical personnel and bystanders. Fortunately, this has been disproven in recent studies, and use has been adopted and incorporated into pre-hospital and advanced trauma life support (ATLS) training. Unfortunately, this training still only reaches healthcare providers who already care for the trauma patients. Fortunately, programs, such as the American College of Surgeons’ Hartford Consensus, now in its fourth iteration, have implemented its “Stop the Bleed” program to train first responders and nonmedical providers in hemorrhage control for mass casualty situations as well as to advocate increased availability of hemostatic dressings and tourniquets and to eventually equal the widespread public awareness of the use of CPR and automatic external defibrillators (AEDs).

Efficiency of transportation has improved, with well-developed private and hospital-based ground and air transport systems capable of moving severely injured patients to appropriate levels of care often within minutes of the time of injury. This has allowed a shift of focus to not just the speed at which a patient is moved but the care provided in route. Expansion of the arsenal of the pre-hospital provider to diagnostic and therapeutic options previously only available in the ED, OR, or ICU is possible. We have had significant success with this process by approaching pre-hospital care not as a separate entity but as a direct extension of care provided in our ED or ICU. This includes initiating early evaluation with StO₂ monitors and providing blood components (3 U PRBCs and 3 U FFP) to every flight team in our healthcare system. This required a coordinated effort with our blood bank to insure little to no product waste. FFP has proven invaluable as an adjunct in treatment of our anticoagulated population with traumatic brain injury. Development of protocols and predefined hemodynamic and clinical triggers, many of which are identical to in-hospital MT protocol triggers, has allowed for the administration of these products without a physician present in the field. The next steps in care potentially will be the availability of cold-stored whole blood and TXA administration.

The area where we continue and must continue to show our commitment to trauma patients is in the energetic care of the providers. None of the advances in civilian or military trauma care discussed throughout this chapter would have been possible without the determination and enthusiasm of trauma heathcare providers. It will only be with this determination that the holy grail of civilian application of military trauma concepts can ever be achieved, the development of walking blood banks. FWB is the best resuscitative fluid; however, the logistics of providing it, including identifying available type-specific donors in a system capable of performing rapid screening for blood-borne illnesses, has remained elusive. This was the initial driving force behind ratio-based resuscitation strategies. The goal was to approximate individual blood components as close as possible to whole blood. This has been studied extensively in multiple prospective and retrospective trials, the most recent being the PROPPR trial which revealed that there likely is a limit in efficacy when attempting to approximate whole blood with reconstituted products in the range of PRBCs:FFP:Plts of 1:1:1 to 1:1:2. The closest civilian system to the military walking blood bank is that seen on the Royal Caribbean Cruise Line. Due to the impracticality of maintaining stored blood products, fleet-wide protocols have been established to utilize a walking blood bank. Donation flowcharts start with related family members and work down an algorithm to pre-identified and screened employee donors and have proven to be the most efficient way of managing a situation requiring massive transfusion, with success in over 37 cases so far. Their success gives some hope to civilian-based systems, but again has been difficult to translate to large academic trauma center with large pool of potential donors, let alone remote critical access hospitals. Overcoming the obstacles to developing this type of system will be challenging, but if as a community, trauma providers continue to show the dedication to the improvement in trauma care we have over the last 50 years, we will make it possible.