Tools
EMS Tactical Damage Control Resuscitation Protocol
Introduction
Damage control resuscitation focuses on temporizing measures that prioritize critical interventions to control hemorrhage, life-threatening injuries, and physiological derangements, followed by staged care. The term "damage control" originated from naval tactics during the First World War, which described interventions to keep a damaged ship combat-capable until definitive repairs could be made.[1] In the prehospital setting, damage control resuscitation (DCR) was initially adopted from long-established principles of damage control surgery. The main goal of DCR is to limit blood loss from hemorrhage and prevent the development of coagulopathy. The original 3-phase approach consisted of initial laparotomy with hemorrhage control, contamination control, intraabdominal packing, and temporary closure in the operating room (OR), followed by correction of metabolic derangements and hemodynamic management in the intensive care unit (ICU), and finally, definitive repairs in the OR after stabilization.[2]
Phase 0 of damage control surgery, termed "Damage Control Ground Zero," was later added, implementing early prehospital measures. This early damage control phase begins upon first contact and consists of interventions that may significantly impact patient outcomes.[3] Data from civilian trauma centers suggests that nearly 50% of deaths happen before hospital arrival, and most of these deaths are associated with massive hemorrhage, a preventable cause of death in the field.[4] Modern prehospital management of trauma consists of emphasizing early time-sensitive resuscitation interventions aimed at treating reversible causes of death, and these interventions include hemorrhage control, establishing intravascular (IV) access, intravenous fluids (blood product transfusion when available), and advanced airway management.[5]
In combat environments, uncontrolled hemorrhage accounts for over 90% of fatalities. Implementing interventions to control bleeding at the point of injury, coupled with prehospital Tactical Combat Casualty Care, has yielded successful outcomes. These interventions are particularly effective when combined with rapid evacuation and prehospital blood resuscitation. Administering blood in the prehospital setting immediately post-injury enhances 24-hour and 30-day survival rates. Therefore, a triad approach encompassing point-of-injury hemorrhage control, rapid evacuation, and prehospital blood resuscitation is instrumental in preserving lives in the face of active hemorrhage.[6]
Hemorrhage control is a high priority in trauma patients, and active life-threatening bleeding should be addressed immediately. This stems from prehospital research that indicated risks from advanced airway interventions in the early phase of the management of trauma patients, leading to increased mortality from delayed transport to definitive care and adverse physiologic effects of intubation of patients in hemorrhagic hypovolemic shock. This triggered a culture change in the prehospital management of trauma and led to the prioritization of hemorrhage/circulation over airway in initial management, shifting resuscitation from Airway, Breathing, Circulation (ABCs) to Circulation, Airway, Breathing (CAB) or Massive Hemorrhage, Airway, Respiration, Circulation, Hypothermia Prevention (MARCH) in military settings.[7][8]
When addressing hypotension in the prehospital setting, early blood product transfusion has consistently been demonstrated to be superior to crystalloid and colloid resuscitation in the field, with possible harm detected in patients who did not receive blood early.[9] The concept of simultaneously managing life-threatening injuries along with expedited transport to a hospital appears to have a favorable impact on patient outcomes in both civilian urban trauma systems and military combat settings.[4][10]
Issues of Concern
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Issues of Concern
Damage Control Ground Zero
Phase zero damage control interventions immediately manage life-threatening injuries, and this includes temporizing measures to control hemorrhage, airway obstruction relief, and decompression of tension pneumothorax. Rapid transport to a hospital should immediately follow these interventions or may also co-occur depending on the availability of personnel and resources.[4][11] Recent evidence indicates that most prehospital interventions do not impact mortality significantly and may result in poor patient outcomes. Increased EMS treatment on the scene has been found to increase mortality. Hemorrhagic shock is a time-critical illness, and interventions such as IV access and airway management have been associated with increased scene time. Little benefit (and potential for harm) has been demonstrated in most cases employing high-volume crystalloid therapy, sedative, and paralytic medications.[12][13][14]
Interventions associated with increased survival rates include hemorrhage control, rapid transport, and airway interventions when indicated. Limited scene time is a critical intervention for prehospital trauma patients, with each minute spent on the scene associated with increased patient mortality. Except for hemorrhage control and early blood product administration in hemorrhagic shock, most patients will benefit more from rapid transport than from other prehospital interventions.[15][16][17]
Damage Control Resuscitation
DCR is based on the premise that coagulopathy in trauma worsens with the disruption of the physiologic balance of whole blood.[18] Prehospital trauma patients in transport are in a critical period defined as the "golden hour," which encompasses the first 60 minutes of the time of injury to definitive hemorrhage control. During this time, opportunities to improve outcomes exist by minimizing physiologic derangements and avoiding the lethal triad of acidosis, coagulopathy, and hypothermia.[19] Military protocols have established a golden hour for delivering combat casualties to an area capable of providing damage control interventions. Subsequent analysis of outcomes of this intervention showed that combat casualties who received blood products or were transferred to centers capable of providing DCR and surgical interventions within an hour of injury had lower mortality.[5]
Remote damage control resuscitation (RDCR), as proposed by the Trauma Hemostasis Oxygenation Research (THOR) network, is applied in prehospital settings where access to a hospital is delayed; 60 minutes have elapsed since the injury. This approach is particularly pertinent when immediate hospital treatment is not easily accessible. The THOR network recommends a hypotensive resuscitation strategy for hemorrhagic shock that aims to maintain systolic blood pressure (SBP) at a level lower than normal (approximately 100 mm Hg). This target is still higher than conventional hypotensive resuscitation protocols for EMS systems with short transport times. The approach to hypotensive resuscitation typically involves three key components: delayed fluid administration, restrictive volume administration, and hypotensive targets. This is designed to balance the need for adequate perfusion with the risk of exacerbating hemorrhage.[20]
Hemorrhage Control
In patients with a clear source of life-threatening external hemorrhage, a simultaneous resuscitation approach should be made that immediately addresses hemorrhage control, followed by basic airway interventions and volume resuscitation. The CAB approach to resuscitation should be the standard of care in severely injured trauma patients.[20]
The first step in managing any life-threatening external hemorrhage is direct pressure. Steady direct pressure on an active source of bleeding effectively controls hemorrhage in most patients. Temporary hemostasis can also be achieved with tourniquet use and topical hemostatic agents for external bleeding, such as dressings.[21] Direct external pressure and compressive dressings should be used in areas not amenable to tourniquet hemostasis.[11][18][22] Patients with suspected unstable pelvic fractures based on the mechanism of trauma can be managed with improvised or commercial pelvic binders. In contrast, patients with femur fractures may benefit from traction splinting, which has shown promise in bleeding control.[23][24]
Hemorrhage in junctional regions, such as the axilla, neck, and groin, once posed significant therapeutic challenges. The advent of approved junctional tourniquets, including the Combat Ready Clamp, SAM Junctional Tourniquet, and Junctional Emergency Treatment Tool, have revolutionized their management. Additionally, a nonabsorbable, expandable, injectable hemostatic sponge (XStat) has been designed to inject deep wounds, providing an effective solution for tamponading bleeding. Innovative hemostatic dressings, such as Combat Gauze or Celox/Celox Rapid gauze, have proven effective for superficial wounds.[25][26][27]
Fluid Resuscitation
Prehospital fluid resuscitation of trauma patients improves patient outcomes in significant trauma, low-resource, and rural emergency settings or when transport time is prolonged. Resuscitation strategies include delayed resuscitation and goal-directed resuscitation. The choice between delayed resuscitation and goal-directed resuscitation with low-volume crystalloid appears to be influenced by the duration of transport time to definitive care. Specifically, delayed resuscitation may be more beneficial when the transport time to definitive care is relatively short. Conversely, goal-directed resuscitation with low-volume crystalloid may be the preferred approach for longer transport time. This suggests that the optimal resuscitation strategy may be dependent on the specific logistical constraints of the prehospital setting.[28]
Balanced blood product resuscitation has consistently been demonstrated to have clear mortality benefits over crystalloid-based therapy in the prehospital setting and upon arrival to a center where patients can receive definitive care.[29] The Committee on Tactical Combat Casualty Care order of fluids for military prehospital resuscitation is (1) liquid cold stored low-titer whole blood, (2) prescreened low-titer O fresh whole blood, (3) plasma, red blood cells, and platelets reconstituted in a 1:1:1 ratio, (4) plasma and red blood cells transfused in a 1:1 ratio, and (5) plasma or red blood cells alone.[19]
Most civilian prehospital EMS services do not have access to blood products for resuscitation. While crystalloid is less than ideal for the resuscitation of hemorrhage, it is frequently the only product available. Some studies have found that allowing for permissive hypotension versus crystalloid resuscitation (no IV fluids versus standard of care) has a mortality benefit, with those who received prehospital crystalloid resuscitation presenting with greater degrees of coagulopathy and anemia than those managed conservatively.[19] Resuscitation protocols of controlled 250 mL crystalloid boluses for profound hypotension (SBP <70 mmHg or absent radial pulse), when compared with liberal crystalloid resuscitation, show early mortality benefits in some patients with hypotension secondary to trauma.[30]
Both military and civilian data indicate that in settings where blood products are not available, controlled crystalloid resuscitation protocols improve mortality by allowing for permissive hypotension. Under this paradigm, blood pressure is no longer artificially elevated, which decreases the risk of displacing newly formed clots after temporary hemorrhage control is achieved. In one study, patients who received lower volumes of crystalloid resuscitation received more blood products on hospital arrival. In contrast, those who received higher volumes of crystalloids received fewer blood products, with worse outcomes observed in the latter group.[22][30] Military tactical resuscitation protocols currently prioritize blood product resuscitation over crystalloids for casualty care of hemorrhagic shock in the field.[18][19][31][32]
The Western Trauma Association recommends that hemodynamically unstable trauma patients should be resuscitated to a target SBP of 100 mm Hg, provided prehospital blood products are available. In regions where prehospital blood products are not part of the standard EMS protocol, crystalloids may achieve a target SBP of 80 mm Hg for patients with a short transport time (less than 20 minutes). However, the resuscitation target for patients with longer transport times should be an SBP of 100 mm Hg. If available, these patients should also be treated with tranexamic acid.[33]
In patients presenting with hypotension and signs suggestive of Traumatic Brain Injury (TBI), especially in the context of multiple injuries and potential internal hemorrhage, hypotensive resuscitation strategies must be tailored to the specific clinical situation. The Western Trauma Association recommends an SBP target of 100 mm Hg for potential TBI cases. In contrast, the Brain Trauma Foundation's 3rd Edition Prehospital Guidelines suggest an SBP above 110 mm Hg in TBI patients, acknowledging a linear relationship between blood pressure and mortality, with higher blood pressure correlating with decreased mortality. They also recognize the need to customize fluid resuscitation strategies in polytrauma patients with TBI and concurrent hemorrhagic shock. Nevertheless, in-hospital guidelines aim for higher blood pressure targets in TBI patients requiring DCR.[33][34][35][36]
Tranexamic Acid
Tranexamic acid (TXA) is an antifibrinolytic drug that inhibits the enzymatic breakdown of fibrin, leading to decreased bleeding. Its role in DCR addresses coagulopathy and bleeding and is beneficial in managing hemorrhagic shock. The Clinical Randomization of an Antifibrinolytic in a Significant Haemorrhage (CRASH)-2 trial revealed that TXA can safely decrease mortality in traumatic bleeding. It demonstrated that TXA decreased the risk of death due to bleeding and all-cause mortality versus placebo when given soon after injury (within 3 hours).[37] TBI patients were later examined in the CRASH-3 trial and were also found to have decreased mortality in the treatment group when given TXA within 3 hours of head injury in patients with mild and moderate TBI.[38] Follow-up clinical trials have subsequently validated these results and support the use of TXA in trauma patients in the prehospital setting.[39][40]
The 2021 Tactical Combat Casualty Care (TCCC) Guidelines recommend a dose of 2 g of TXA be administered through a slow IV or IO infusion.[41] This single 2 g dose replaces the previous dosing regimen of 1 g IV TXA over 10 minutes followed by 1 g IV over 8 hours infusion recommended by the CRASH-2 Trial.[37][38][42][38] Timing is critical when considering treatment with TXA; a meta-analysis of WOMAN and CRASH-2 trials found that for every 15 minutes of delay in administering treatment, there was a 10% reduction in survival benefit from treatment. After 3 hours, TXA is ineffective and may increase the risk of death due to bleeding.[37][43][44] The IV route of administration of TXA is a major obstacle to widespread use in the prehospital setting; studies are ongoing on the viability of the intramuscular route of administration for TXA.[44]
Calcium
Hypocalcemia is a prevalent issue in trauma patients with active bleeding. The administration of a single unit of citrated blood product can exacerbate this condition, potentially reducing ionized calcium to critical levels (<0.9 mmol/L). Though civilian data have yet to support the practice, the military Joint Trauma System (JTS) DCR guidelines recommend that patients in hemorrhagic shock receive 1 gram of intravenous or intraosseous calcium during or immediately following the transfusion of the initial unit of blood product. Calcium gluconate is considered safer than calcium chloride in the prehospital setting due to the possible risk of extravasation. Calcium administration should be repeated after every 4 units of blood products during ongoing resuscitation. To prevent citrate toxicity, 1 gram of calcium should be administered for every 4 units of blood product infused.[45][46][47]
Clinical Significance
Prehospital EMS services should prioritize blood product resuscitation of hemorrhagic shock in trauma patients over crystalloid resuscitation when available.[18][19] A tailored approach is necessary for prehospital trauma resuscitation. The potential risks and benefits of exacerbating bleeding versus optimizing hemodynamics should be considered when administering IV fluids, particularly when blood products are unavailable.[20]
The administration of crystalloid should given in controlled boluses of 250 mL for severe hypotension to preserve organ perfusion, with a target SBP of 80 to 90 mm Hg for patients with short transport times (<20 minutes).[33] In EMS systems where blood products are accessible as resuscitation fluids, prehospital providers should aim to resuscitate patients with hemorrhagic hypovolemic shock to a target SBP of 100 mm Hg. During extended transport times (>60 minutes), regardless of resuscitation fluid availability, the goal should be an SBP of 100 mm Hg, and SBPs below 90 mm Hg should be avoided. The proposed upper limit during active resuscitation is 110 mm Hg. Current evidence suggests that this SBP range of 90 to 110 mm Hg in patients receiving blood products is optimal to enhance patient outcomes, and lower SBP targets in patients receiving crystalloids should help mitigate the risk of exacerbating coagulopathy and clot displacement.[20][33] In hemodynamically stable trauma patients, the best approach is to establish IV access but withhold fluid administration unless a change in the patient’s status or hemodynamics suggests fluid administration would likely benefit the patient during transport.[48][49]
Effective DCR strategies in military and civilian EMS systems should focus on an initial assessment following a CAB or MARCH approach. This includes rapid hemorrhage control using direct pressure and mechanical adjunct devices such as tourniquets, junctional devices, and nonabsorbable expandable injectable hemostatic sponges. This should be followed by a fluid resuscitation strategy that prioritizes whole blood as the ideal resuscitation fluid, along with TXA.
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