EMS Tactical Damage Control Resuscitation Protocol

Excerpt

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. 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.

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. 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. 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.

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.

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.

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. 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.