Damage Control Resuscitation in Penetrating Trauma: Rules of the Game

“One of the most frustrating situations ever encountered by the operating surgeon is an open wound in a patient whose blood will not clot and cannot be made to clot.” In their seminal 1981 description of damage control surgery for exsanguinating trauma patients, the veracity of Stone and colleagues’ statement remains today. The techniques of damage control surgery in the severely injured patient have evolved since the term was coined in the 1990s. However, the underlying philosophy remains the same and its benefits in this patient population have been reaffirmed and improved with ongoing military and civilian experiences. Patients arriving with multiple complex injuries and in hemorrhagic shock will benefit from initial management of life-threatening hemorrhage and control of ongoing contamination before additional resuscitation in preparation for later definitive management of their injuries. Hemostatic, goal-directed resuscitation is a cornerstone in this overall strategy. Although not validated, several techniques, including point-of-care viscoelastic testing (i.e., thromboelastography and rotational thromboelastometry), have emerged to help guide these efforts. Identifying which patients and which injuries benefit from a damage control approach is an ongoing debate for which no strict guidelines exist. Rapid pre- and intraoperative identification of patients who will benefit from damage control strategy is a frontier in the field deserving ongoing study. Finally, there are potential complications associated with overuse of damage control strategies, making its appropriate application an important point for consideration on a patient-by-patient basis.