Damage-control resuscitation and permissive hypotension — Rapid

Synopsis

Use haemostatic, temperature-conscious resuscitation while bleeding remains uncontrolled, understand when restricted pressure targets are unsafe, and link physiology to rapid damage-control intervention.

Damage-control resuscitation combines restricted volume before control, haemostatic blood-component support, tranexamic acid, warming, calcium surveillance and rapid anatomical haemostasis.
Permissive hypotension is a temporary bleeding-control strategy, not a fixed number or endpoint; judge consciousness, pulses, refill, lactate and response within the local protocol.
Do not use a low-pressure strategy indiscriminately in traumatic brain or spinal cord injury, where avoiding hypotension and maintaining perfusion takes priority.

Key red flags

Persistent shock, a transient response or escalating blood requirement means damage-control resuscitation is failing unless definitive haemorrhage control is occurring simultaneously.

Investigation priorities

First-line serial blood gasFirst stepFirst line

Track oxygen debt, ventilation and ionised calcium during resuscitation.

Preferred viscoelastic assay when availablePreferred

Individualise haemostatic component therapy rapidly.

Management branches

InitialStart damage-control resuscitation

Major bleeding is suspected before anatomical control.

Control external and junctional bleeding, splint fractures and apply a trochanteric pelvic binder when indicated while activating the major-haemorrhage protocol.
Use warmed blood components with minimal crystalloid, administer early tranexamic acid and establish rapid access and monitoring.

Key medicines

Tranexamic acidGive 1 g by intravenous injection over 10 minutes, then infuse 1 g intravenously over the following 8 hours; initiate as soon as possible after injury and within 3 hours.

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