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.
- Prefer warmed blood components to large crystalloid loads during active major bleeding and use the local major-haemorrhage pack until laboratory or viscoelastic results individualise therapy.
- Give adult tranexamic acid 1 g IV over 10 minutes followed by 1 g over 8 hours as early as possible and within 3 hours of injury.
- Measure core temperature, ionised calcium, blood gas, fibrinogen and platelets repeatedly; correct the physiology that permits clot formation while the source is treated.
- Damage-control surgery controls contamination and bleeding quickly, accepting temporary packing or closure when definitive reconstruction would prolong lethal physiological stress.
- Once haemostasis is achieved, transition deliberately to normal perfusion, targeted component replacement, definitive repair, critical-care surveillance and thromboprophylaxis planning.
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.
Traumatic brain injury, spinal cord injury, pregnancy and some older or chronically hypertensive patients can be harmed by indiscriminate permissive hypotension because organ perfusion must be preserved.
Core hypothermia, low ionised calcium, worsening acidosis, low fibrinogen or diffuse microvascular ooze signals a self-reinforcing haemostatic collapse requiring immediate correction and source control.
Investigation priorities
Track oxygen debt, ventilation and ionised calcium during resuscitation.
Individualise haemostatic component therapy rapidly.
Management branches
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.
- State whether restricted pressure is acceptable or whether head, spinal, pregnancy or other physiology requires stronger perfusion support.
- Mobilise the relevant surgical and interventional team and select CT only if response makes the journey safe and useful.