Damage-control resuscitation of traumatic haemorrhage

This is class III to IV haemorrhagic shock from intra-abdominal bleeding, and the priority is the simultaneous resuscitation and the control of the haemorrhage, because the lethal triad of acidosis, hypothermia and coagulopathy will kill the patient if it is allowed to develop.^[4]

Activate the massive transfusion protocol immediately with a single call to the blood bank, and assemble the trauma team. Apply the primary survey with high-flow oxygen and the control of any external haemorrhage. Establish large-bore intravenous access. Resuscitate with blood products in a balanced ratio approaching 1-to-1-to-1 plasma-to-platelets-to-red-cells, not crystalloid, because the crystalloid dilutes the clotting factors and worsens the coagulopathy.^[2] Give tranexamic acid 1 gram intravenous bolus then 1 gram over eight hours, within three hours of injury, since the CRASH-2 trial showed it reduces mortality from traumatic bleeding within this window.^[1] Monitor and replace the ionised…

Apply permissive hypotension — tolerate a systolic of 80 to 90 mmHg until the bleeding is controlled — to avoid disrupting early clots and accelerating the haemorrhage, unless there is a traumatic brain injury that requires a higher pressure.^[4]

The definitive haemorrhage control is pursued in parallel. A FAST at the bedside confirms the intra-abdominal bleeding. In the unstable blunt-trauma patient with a positive FAST and class III to IV shock, the destination is the operating theatre for a damage-control laparotomy, not the computed tomography scanner. The resuscitation continues into theatre and the intensive care unit, where the lethal triad is corrected and the physiology restored before the definitive surgical repair.^[4]