Damage control resuscitation in trauma

Meet the patient

A 24-year-old motorcyclist rolls into the trauma bay 20 minutes after a high-speed crash — pale, diaphoretic, confused (GCS 13), BP 74/48, HR 138. He has a deformed pelvis, an open tibial fracture bleeding externally, a tense distended abdomen, a FAST positive in the right upper quadrant, lactate 7.8, INR 1.8, core temperature 34.6 °C. There is no head injury.[1]

The question this patient forces on you at 3 a.m. is the question every major haemorrhage forces: do I resuscitate him to a normal blood pressure, or do I let him run low until the bleeding is surgically controlled? The wrong answer restarts a spiral that kills him within the hour. Hold that question, and the four pillars below are its answer.[2]

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1. [1]CRASH-2 Trial Collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial Lancet, 2010.PMID 20554319
2. [2]Indorewala Y, Nasef Y, Jayagopi K, et al. Permissive hypotension in adult trauma: A systematic review of outcomes across clinical settings, injury type, and resuscitation strategies Am J Emerg Med, 2026.PMID 42030689
3. [3]CRASH-2 Collaborators, Roberts I, Shakur H, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial Lancet, 2011.PMID 21439633
4. [4]Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) Study Arch Surg, 2012.PMID 22006852
5. [5]Holcomb JB, Tilley BC, Baraniuk S, et al.; PROPPR Study Group. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial JAMA, 2015.PMID 25647203
6. [6]CRASH-3 Trial Collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial Lancet, 2019.PMID 31623894
7. [7]Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury: a randomized clinical trial JAMA, 2020.PMID 32897344
8. [8]Spaite DW, Hu C, Bobrow BJ, et al. Optimal out-of-hospital blood pressure in major traumatic brain injury: a challenge to the current understanding of hypotension Ann Emerg Med, 2022.PMID 35339285
9. [9]Gonzalez E, Moore EE, Moore HB, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays Ann Surg, 2016.PMID 26720428
10. [10]Ho KM, Leonard AD. Concentration-dependent effect of hypocalcaemia on mortality of patients with critical bleeding requiring massive transfusion: a cohort study Anaesth Intensive Care, 2011.PMID 21375089
11. [11]Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers Ann Surg, 2012.PMID 22580944
12. [12]Alghanem H, Liu NC, Gupta A, et al. Ratios of calcium to citrate administration in blood transfusion for traumatic hemorrhage: a retrospective cohort study Transfusion, 2024.PMID 39351914