Principles and Components of Resuscitation Damage Control: scoping-review

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Introduction. The management of patients with polytrauma complicated by massive hemorrhage represents one of the most serious and relevant challenges in modern disaster medicine, emergency care, and military surgery. The concept of Damage Control Resuscitation (DCR), which is the second stage of the "damage control" surgical strategy, was developed to improve survival in this extremely severe category of casualties [3]. The main goal of DCR is the prevention or timely correction of life-threatening conditions collectively known as the "lethal triad": trauma-induced coagulopathy (TIC), hypothermia, and acidosis. In recent years, the "lethal tetrad" is increasingly discussed, adding hypocalcemia as an independent risk factor for adverse outcomes. DCR comprises a complex of interconnected, dynamic strategies aimed at rapid stabilization of vital functions, cessation of ongoing bleeding, and correction of coagulopathy, thereby preparing the patient for subsequent definitive surgical repair of injuries [3, 5]. Importantly, the timeframe for DCR application is continually expanding, with increasing emphasis placed on its early initiation, even in the prehospital setting (remote damage control resuscitation, RDCR) [1]. Given the rapid development of medical knowledge, the emergence of new technologies, and pharmacological agents, the core components and tactical approaches of DCR require regular review and updating based on current scientific data. This scoping review aims to analyze contemporary research in the field of DCR published over the last five years to summarize current knowledge and identify promising directions.

Objective: To evaluate the structure of the current literature on the topic "damage control resuscitation" and to conduct a qualitative analysis of publications in its directions.

Materials and Methods. A systematic literature review using the scoping review format was conducted in accordance with PRISMA-ScR guidelines. This review format was chosen due to the prevalence of studies with low to moderate quality and the large volume of heterogeneous literature, making a classic systematic review with meta-analysis difficult. The search for relevant publications was performed in electronic databases including PubMed, Cochrane Library, Google Scholar, eLIBRARY.ru, and Cyberleninka for the period from 2017 to 2022, with no language restrictions. Keywords used included: damage control resuscitation, damage control, blood transfusion, hypothermia, acidosis, massive bleeding, coagulopathy, both independently and in combination. Inclusion criteria were published studies of any design (protocols, reviews, RCTs, retrospective, cohort, etc.) describing the application of DCR or its individual components in adult patients with polytrauma and massive hemorrhage. Duplicate publications, animal studies, pediatric and obstetric studies, and papers published before 2017 were excluded. From the initial 309 sources found, after screening titles, abstracts, and full texts, 82 publications met the inclusion criteria and underwent qualitative analysis.

Results. The analysis of the selected literature allowed for the identification of the main trends in the evolution and key components of the modern DCR strategy, aimed at combating the "lethal triad/tetrad" and improving outcomes in patients with polytrauma and shock.

• Fluid Therapy: It has been convincingly shown that the previous tactic of massive crystalloid fluid infusion is not the optimal strategy in traumatic shock. It is associated with a high risk of developing dilutional coagulopathy and hyperchloremic acidosis, which worsens the patient's condition [2, 4]. Modern approaches favor low-volume fluid therapy, involving the administration of less than 1000 mL (including the prehospital stage) of balanced crystalloid solutions [2]. This strategy is often combined with the principle of permissive (controlled) hypotension, aiming to maintain systolic blood pressure (SBP) at 80-90 mmHg [2]. This approach allows for adequate perfusion of vital organs while minimizing the risk of clot disruption, exacerbation of bleeding, and excessive dilution of clotting factors. An important exception is patients with concomitant traumatic brain injury (TBI), for whom target SBP values should be higher (100-110 mmHg) to maintain cerebral perfusion pressure [2]. There is no reliable evidence supporting the advantage of hypertonic NaCl solutions, and routine use of albumin is not indicated due to insufficient data on efficacy and safety [2]. Hydroxyethyl starch (HES) solutions should not be used in polytrauma patients due to the risk of acute kidney injury (AKI) and worsening coagulopathy [2]. It is emphasized that every minute of delay in initiating blood transfusion during ongoing hemorrhage increases mortality.

• Hemotransfusion: Massive transfusion (MT) is now considered the primary method for restoring circulating blood volume (CBV) and delivering clotting factors and oxygen carriers in traumatic shock [4]. The vast majority of studies confirm the appropriateness of early MT with blood components in a balanced volume ratio of 1:1:1 (fresh frozen plasma : packed red blood cells : platelet concentrate) [2]. Differences in described quantitative ratios (e.g., 6:4:2 or 4:4:1) are often explained by varying standard volumes of blood component bags in different countries, but the ultimate goal is transfusion in a 1:1:1 volume ratio [1]. Transfusion of whole blood, especially universal donor O Rh-negative, or the use of autotransfusion (Cell Saver devices) [3, 4] are considered effective alternatives to component therapy, particularly in military settings, when components are scarce, or to reduce the time to transfusion initiation. Implementing massive transfusion protocols (MTPs) in medical facilities not only standardizes therapy but also solves logistical problems and prepares staff for mass casualty incidents [1]. The use of cryopreserved platelets is a promising direction, improving the logistics of their storage and availability. The critical importance of early correction of hypofibrinogenemia is noted, as fibrinogen is the first clotting factor to reach critically low levels during hemorrhage. Cryoprecipitate (target dose equivalent to approximately 4 g of fibrinogen or 15-20 units of cryoprecipitate) or fibrinogen concentrate (not registered in the Russian Federation, availability varies globally) is used for this purpose.

• Coagulopathy Correction: Trauma-induced coagulopathy (TIC) is a complex pathological state developing both immediately after severe trauma (acute traumatic coagulopathy) and during resuscitation efforts (resuscitation coagulopathy) [5]. It is based on a combination of clotting factor deficiency, tissue hypoperfusion, endothelial dysfunction, and a systemic inflammatory response with platelet activation, forming a vicious cycle and leading to the exhaustion of the hemostatic system [5]. TIC can manifest with different fibrinolysis phenotypes (hyperfibrinolysis, physiologic fibrinolysis, fibrinolysis shutdown), with hyperfibrinolysis being the most common and associated with high mortality [2, 5]. For timely diagnosis of TIC and monitoring of hemostatic therapy, standard coagulation tests (PT >18s, INR >1.5-1.6, aPTT >60s, platelets <50,000-100,000/µL, fibrinogen <100 mg/dL) are less informative than viscoelastic tests (Thromboelastography - TEG, Rotational Thromboelastometry - ROTEM). These methods allow assessment of all stages of hemostasis in real-time and play a key role in personalizing therapy [5]. The ABC and TASH scores are also used to assess the need for MT. A crucial element of the modern DCR strategy is the early administration (ideally within the first hour, but no later than 3 hours post-injury), including the prehospital stage, of the antifibrinolytic agent tranexamic acid (TXA) [1]. The dosing regimen proposed in the CRASH-2 study (loading dose of 1 g IV over 10 minutes, followed by an infusion of 1 g over 8 hours) is most commonly used, reducing fibrinolysis, blood loss volume, and the need for blood transfusion [1]. Alternative routes of administration, such as intramuscular, are also being investigated.

• Temperature Control: Hypothermia, defined as a body temperature <35°C, is an independent risk factor for death in polytrauma and a key component of the "lethal triad" [3]. It exacerbates coagulopathy (by reducing the activity of clotting enzymes and platelet function) and metabolic acidosis. Therefore, starting from the prehospital stage, continuous body temperature monitoring and active prevention of further cooling are necessary, using both passive (removing wet clothing, covering with emergency/thermal blankets, using heat and moisture exchangers (HMEs) in the ventilator circuit, external warming of the ventilator circuit, warming the body surface with warm air) and active warming methods (infusion of warmed fluids through special devices, irrigation of the bladder and stomach lavage with warmed fluid, forced-air/convective warming) [1, 3].

• Acidosis Correction: Metabolic acidosis in polytrauma arises from tissue hypoperfusion and the shift to anaerobic metabolism with lactate accumulation [1]. It is also aggravated by renal dysfunction and the systemic inflammatory response [5]. Acidosis has a pronounced negative effect on the hemostatic system, reducing the activity of most clotting factors (e.g., the activity of factors VIIa and Xa/Va decreases by 70-90% when pH drops from 7.4 to 7.0) and impairing platelet function [1]. The cornerstone of acidosis correction is the restoration of adequate tissue perfusion (by stopping hemorrhage and providing adequate fluid and transfusion therapy) and oxygenation (ensuring airway patency, adequate lung ventilation, and oxygen delivery) [1]. Routine use of buffer solutions, such as sodium bicarbonate or tromethamine (THAM), has not shown convincing benefits in improving outcomes and is not recommended for widespread use [1, 3]. Important laboratory markers for assessing shock severity and the adequacy of ongoing therapy are lactate levels and base excess (BE), which sensitively reflects the degree of tissue hypoperfusion [1].

• Hypocalcemia Correction: Hypocalcemia (ionized calcium level <0.9 g/L or <1.1 mmol/L depending on units used) is increasingly recognized as the fourth component of the "lethal diamond/tetrad" in traumatic shock. Low calcium levels are an independent predictor of mortality and the need for MT, as calcium is essential for many steps of the coagulation cascade and for maintaining myocardial contractility. The development of hypocalcemia is facilitated by massive transfusion, as sodium citrate, used as an anticoagulant in blood components, binds ionized calcium. It is suggested that whole blood may have an advantage as it contains less citrate per unit volume compared to the total volume of components [3]. It is necessary to monitor ionized calcium levels and promptly correct them with calcium preparations, possibly starting as early as the prehospital stage during MT.

• Prehospital Stage (RDCR): Modern research unequivocally points to the critical importance of initiating resuscitation measures as early as possible, even before the patient arrives at the hospital (remote DCR) [1]. Effective actions in the prehospital setting can prevent the development or worsening of the "lethal triad/tetrad." Key elements of RDCR include: 1) Immediate control of visible external hemorrhage using tourniquets on limbs, hemostatic dressings (especially for junctional zones – axilla, groin, neck) or wound packing (e.g., with a Foley catheter balloon); application of a pelvic binder if an unstable pelvic fracture is suspected [3]. 2) Ensuring airway patency (including placement of supraglottic airway devices or endotracheal intubation if necessary) and providing adequate respiratory support/oxygen therapy (especially with TBI) [4]. 3) Reducing on-scene time and ensuring rapid transport to a specialized trauma center [2], except in situations requiring immediate life-saving interventions on site (CPR, decompression of tension pneumothorax, pericardiocentesis) [4]. 4) Securing reliable vascular access (peripheral intravenous or intraosseous) [4]. 5) Early intravenous administration of TXA (within the first 3 hours) [1]. 6) Applying the strategy of permissive hypotension (SBP 80-90 mmHg, 100-110 mmHg with TBI) [2]. 7) Considering prehospital blood transfusion with components, whole blood, or lyophilized plasma during prolonged transport (>30 minutes) [3]. 8) Using lyophilized plasma as a convenient component for the prehospital stage [3]. 9) Actively warming the patient to prevent hypothermia [1]. 10) Employing multimodal analgesia for adequate pain relief [4]. 11) Using simple mnemonic aids (e.g., C-ABCDE, MARCH, SMART, AVPU, SAMPLE) to standardize and sequence personnel actions [4]. The eFAST protocol may be used for rapid diagnostics at the scene [3].

• Adjunctive Methods: Besides TEG/ROTEM, which help optimize transfusion strategies and have economic benefits, other technologies can be integrated into the DCR complex. The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) – inserting a balloon via the femoral artery and inflating it in the aorta to temporarily stop non-compressible torso or pelvic hemorrhage and increase central blood pressure – has been described [3]. This method can buy time for transport and preparation for surgery, especially in pelvic trauma, but data on its impact on outcomes are still inconclusive and require further study. In the stage of late complications of polytrauma (sepsis, multiple organ dysfunction syndrome), often associated with a massive systemic inflammatory response [5], extracorporeal blood purification techniques (e.g., hemoperfusion) may be used to remove endotoxins and inflammatory mediators [5]. Extracorporeal membrane oxygenation (ECMO) currently has limited descriptions of use in polytrauma (e.g., during pneumonectomy), but its potential in managing severe ARDS or refractory shock within the DCR framework warrants further investigation.

Conclusion. Damage Control Resuscitation has evolved into a comprehensive, multicomponent, and dynamically developing strategy for the intensive care of patients with polytrauma and massive hemorrhage. Its primary goal is to combat the fatal "lethal tetrad" (coagulopathy, hypothermia, acidosis, hypocalcemia) at all stages of care. Modern approaches to DCR include a strong emphasis on early intervention starting in the prehospital phase (RDCR) [1, 2, 3, 4], strict control and limitation of crystalloid infusion [2, 4] using principles of permissive hypotension [2], early initiation of balanced massive transfusion of blood components (or whole blood) in a 1:1:1 volume ratio [1, 2, 3], mandatory early use of tranexamic acid [1], targeted monitoring and correction of TIC using viscoelastic methods (TEG/ROTEM) and replenishment of fibrinogen [5], active patient warming [1, 3], and monitoring and correction of other metabolic disturbances, including acidosis [1, 3] and hypocalcemia. The implementation of adjunctive methods, such as REBOA and extracorporeal therapies [5], may further improve treatment outcomes in selected patient categories.

This scoping review revealed that a significant portion of the evidence base for DCR is still derived from literature reviews and retrospective studies with low levels of evidence. This underscores the urgent need for further high-quality prospective studies and randomized controlled trials (RCTs) to clarify indications, optimal regimens, and the comparative effectiveness of individual DCR elements. Conducting multicenter studies within specific national healthcare systems is particularly relevant to assess the feasibility and specifics of adapting global best practices to local realities, as well as to clarify the organizational, legal, and economic aspects of widespread implementation of modern DCR protocols into clinical practice [4].

About the authors

Igor Vyacheslavovich Sbitnev

Tver State Medical University

Email: swampsbitnev@yandex.ru
ORCID iD: 0000-0003-4433-8671
SPIN-code: 9922-9264
https://t.me/Sbitnev3000

student

Russian Federation, 4 Sovetskaya street, 170100, Tver, Russian Federation

Artyom Romanovich Rasskazov

Tver State Medical University

Email: rv_temaa@mail.ru
ORCID iD: 0009-0007-0645-2410
https://t.me/rv_temaa

Student

Russian Federation, 4 Sovetskaya street, 170100, Tver, Russian Federation

Maksim Aleksndrovich Petrushin

Tver State Medical University

Author for correspondence.
Email: maxi.petrushin@yandex.ru
ORCID iD: 0000-0002-2780-5138
SPIN-code: 6864-4349

Assistant of the Department of Emergency Medicine and Disaster Medicine

Russian Federation, 4 Sovetskaya street, 170100, Tver, Russian Federation

References

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