Episode 33: Damage Control Resuscitation Part 2

Author: Eoghan Colgan    @eoghan_colgan
Special Guest: Pete Davis



Podcast _ Pete Davis 2.png

Guest Bios

Lt Col. Pete Davis


Pete Davis is a Consultant in Emergency Medicine in the Defence Medical Services (Royal Army Medical Corps), based at the Queen Elizabeth University Hospital here in Glasgow.

He has a background in prehospital and wilderness medicine, highlights of which include: retrieval work in New Zealand, a fellowship with HEMS London, and helping to pioneer both the Emergency Medical Retrieval Service in Scotland and the military forward aeromedical evacuation system that operated during the Afghanistan conflict ("MERT").

Successfully mixing both business and pleasure, he has climbed or skied throughout the world during many years of expeditions.

Show Notes

Eoghan discusses Damage Control Resuscitation with Pete Davis, a Consultant in Emergency Medicine and Prehospital Medicine, and an Army Medic who has served in multiple conflicts around the world. Find out what this concept is and how to apply it to your sickest trauma patients.

Take Home Points

Emergency room Priorities

  • Ongoing resuscitation

  • Need to differentiate patients injuries

  • Create a management plan based on defined or predicted injuries


 Ongoing resuscitation (CABCDE approach)

  • Ongoing haemorrhage

    • Could exchange tourniquet for a pneumatic tourniquet

    • Do this in presence of a surgeon ideally who can assess the injury and plan a surgical strategy

  • If AB not secured – emergency anaesthetic and ventilation, with chest decompression (formal chest drains) if required

Blood product resuscitation

  • If no machines available:

    • Fluid resuscitation:

      • Balanced haemostatic resuscitation

      • Ratios vary between centres

      • Military practice : RBC, FFP + Platelets in 1:1:1 ratio

    • Practically speaking:

      • Start with what’s immediately available 

        • Typically O negative blood or O positive for men or women of non-childbearing age

        • Also universal donor fresh frozen plasma should be available

      • When full cross-match is done then achieve balanced ratio when other products are available

      • There is no place for crystalloid in a balanced haemostatic resuscitation

  • Machines that guide haemostatic resuscitation

    • Thromboelastography (TEG) (see below)

    • Rotational Thromboelastomotery (RoTEM)

      • Takes a blood sample and allows it to clot then subjects it to stress

        • Gives a graphical representation of the quality of the clot that has been formed by the patient

        • Users have to interpret it, but it helps guide when to give more of one or other products

  • How much blood product to give:

    • Choosing endpoint for haemostatic resuscitation is not an exact science – will be based on:

      • Physiological parameters such as heart rate and systolic blood pressure (aiming for around 100mmHg) and urine output

      • Serial arterial blood gases – is the acidaemia correcting

      • Ongoing coagulopathy with repeated RoTEM measurements

Whole Blood

  • Ideally we would replace like for like

  • But there are technical difficulties around storing blood

  • And risk of transmission of BBV’s

  • There is experience of this in the military and is very effective

  • But needs to be collected from a pre-screened donor panel

  • Storage is probably around 48 hours maximally

Dried Blood Products

  • Freeze-dried Plasma has grown in popularity due to its ease of storage, transport and reconstitution in the field

Permissive hypotension

  • Concept came about through the management of ballistic type injuries

  • The idea that accepting subnormal blood pressures will stop the disruption of the patients first attempts to clot the injuries (avoid ‘popping the clot’)

  • The use of permissive hypotension is limited to the management of penetrating torso or abdominal trauma, with the expectation that there will be emergency surgical vascular control imminently

  • There is no place for permissive hypotension in blunt trauma

Controlling Internal Haemorrhage

  • If unable to externally control haemorrhage then the requirement is surgical intervention

  • There are some temporising measures that can be used in the ED, for example:

    • REBOA – Retrograde Endovascular Balloon Occlusion of the Aorta

      • A balloon catheter is inserted through one of the femoral arteries, and balloon fed upo to the descending aorta where it can be inflated to temporarily restrict blood flow to distal damaged blood vessels

      • It’s the endovascular equivalent of cross-clamping the aorta

Damage Control Surgery

  • Some trauma patients are on the cusp of life and have entered the lethal triad of trauma.

    • The crux of the matter is they do not have the physiological reserve to undergo a long definitive operative procedure 

  • Damage Control Surgery has one of two purposes:

    • To arrest ongoing bleeding

    • To minimise contamination if the bowel or urogenital tract has been breached

  • The right time for dame control surgery: 

    • Evidence of ongoing bleeding and persistent hypothermia, acidaemia and coagulopathy

    • It then needs to be done as rapidly as possible

    • Maximum time they should be on the operating table is around 40 minutes

      • Surgeon does the minimum to preserve healthy tissue and remove devitalised tissue, and remove any contamination

      • No attempt made to close the abdominal wall to avoid abdominal compartment syndrome (cover with a clear dressing)

When to CT?

  • CT is excellent at defining the extent of the injuries but gaining emergency vascular control may trump CT

    • This would be an opportunity to control bleeding and restore circulating volume (whilst also treating coagulopathy)

    • Can then go to CT to define the extent of injuries and plan more definitive care

Abdominal Compartment Syndrome

  • A massive systemic inflammatory response to the injury itself

  • SIRS is then multiplied by operating on the patient

  • The bowel can then become really oedematous and if this occurs in an enclosed space, it can lead to bowel ischaemia

Intensive Care – Phase 4

  • Patients can go to ICU from ED with or without damage control surgery

  • Principles are:

    • Restore normal physiology as much as possible

    • Ongoing correction of the lethal triad of trauma

    • Optimising ventilation, tissue perfusion and oxygenation


 Take-Home Pearl:

  • To be an effective team-leader you need to focus on the human factors

  • When to be ascertive and when to be a good listener/follower.


Thromboelastography (TEG) click image for more information

Thromboelastography (TEG) click image for more information

Rotational Thromboelastometry (RoTEM) click image for more information

Rotational Thromboelastometry (RoTEM) click image for more information

Hannah BellComment