Updated October 2025
Trauma Surgery
Trauma Resuscitation: Updates in Damage Control Surgery (DCS) and Resuscitation (DCR)
Contemporary damage control emphasizes early physiologic stabilization, judicious patient selection for abbreviated operations, integration with balanced DCR, and staged definitive repair. Recent consensus and reviews highlight refined indications, the growing role of REBOA as a DCR adjunct, and the need for core outcome sets to standardize research. Evidence suggests DCS improves survival in select polytrauma and penetrating injury, but overuse may increase complications—therefore, decision-making anchored in physiology is essential.
Clinical question
What are the latest evidence-based updates in damage control surgery and resuscitation for trauma patients, including indications, operative strategies, and outcomes?
Damage Control SurgeryDamage Control ResuscitationTraumaHemorrhage ControlREBOAMassive TransfusionPenetrating and Blunt Trauma
Key points
Consensus updates
AAST/ACS guidance refines DCR principles and integrates DCS indications, stressing physiology-first decision-making and minimizing crystalloid with balanced transfusion [1], [2].
REBOA as adjunct
REBOA is highlighted as a key adjunct to DCR when used by trained teams with strict indications, potentially reducing hemorrhage and buying operative time [3].
Standardizing outcomes
A core outcome set for damage control laparotomy aims to harmonize endpoints (e.g., fascial closure, abdominal complications, long-term function) and reduce heterogeneity in future trials [4].
Patient selection matters
Evidence suggests DCS improves survival in select multiple-trauma and exsanguinating patients, while indiscriminate use increases morbidity—choose based on shock, acidosis, coagulopathy, and injury pattern [5], [6].
Perioperative resuscitation
Modern DCR prioritizes early hemostatic transfusion, limited crystalloid, and rapid correction of coagulopathy, hypothermia, and acidosis to enable staged definitive repair [7], [8].
Evidence highlights
Permissive hypotension, hemostatic resuscitation, rapid hemorrhage control
DCR Pillars
Abort operation when physiology deteriorates to avoid lethal triad
Key DCS Aim
REBOA as a potential “fourth pillar” of DCR
Emerging Adjunct
From Door to Definitive Repair: Contemporary DCS/DCR Workflow
A physiology-driven, staged approach integrating resuscitation with abbreviated operative control, ICU optimization, and delayed reconstruction.
1
Identify candidates rapidly
Screen for profound shock, SBP <90, active hemorrhage, pH <7.2, lactate >4–5 mmol/L, INR >1.5, temperature <35°C, impaired mental status, or massive transfusion activation. Consider mechanism (penetrating torso, severe blunt polytrauma) [1], [6], [9], [10].
2
Initiate DCR immediately
Activate balanced MTP (plasma:platelets:RBCs approximating 1:1:1), minimize crystalloid, maintain permissive hypotension until hemorrhage control, warm aggressively, and correct coagulopathy with factor concentrates/cryoprecipitate as indicated [1], [7], [8].
3
Abbreviated hemorrhage control (DCS Stage 1)
Perform rapid maneuvers: pack/ligate/temporary shunt, stapled bowel control, damage control thoracotomy if needed; avoid time-consuming repairs. Abort when physiology worsens to prevent lethal triad [6], [9], [10].
4
Temporary closure and ICU optimization (DCS Stage 2)
Use temporary abdominal closure (e.g., negative pressure systems), continue DCR, normalize temperature, coagulation, pH, and lactate, and plan return to OR within 24–48 hours for definitive repair [6], [4], [7].
5
Definitive reconstruction (DCS Stage 3)
Once stabilized, restore anatomy (vascular repair, bowel anastomosis/ostomy, definitive chest/abdominal closure). Use core outcomes to track recovery and complications [6], [4].
Who Benefits and Which Tools Matter Now
Physiology, not anatomy alone, drives DCS choice. Adjuncts like REBOA and negative-pressure closure may expand safe windows for staged repair.
Indications for DCS
Refractory hemorrhagic shock, escalating vasopressors, or ongoing transfusion needs [1], [6]
Worsening acidosis/coagulopathy/hypothermia intraoperatively—trigger to abbreviate [6], [9], [10]
Complex multi-cavity injury where rapid control supersedes reconstruction [6]
Massive transfusion activation with expected prolonged operation [1]
Timing and the “Golden Hour”
Early operative control remains critical; prolonged first operation increases risk of physiologic collapse [11], [6]
Return to OR typically targeted within 24–48 hours after ICU optimization [6]
DCR Essentials
Balanced MTP (1:1:1 or lab/viscoelastic guided), limit crystalloids [1], [7], [8]
Warmers, calcium repletion, fibrinogen/cryoprecipitate as indicated [1], [7]
Permissive hypotension until hemorrhage control in non-TBI patients [1], [8]
REBOA Use
Consider for torso hemorrhage with impending arrest when surgical control is imminent; Zone I or III placement per injury pattern [3]
Requires trained teams, protocols, and strict time limits to mitigate ischemic complications [3]
Abdominal Closure Strategy
Temporary negative-pressure closure to preserve domain and facilitate re-entry [4], [7]
Track rates of primary fascial closure, enteroatmospheric fistula, ventral hernia as key outcomes [4]
Outcome Monitoring
Adopt core outcome set for DCL: mortality, resource use, fascial closure, abdominal complications, patient-centered recovery [4]
Audit variation in DCL utilization to avoid overuse and reduce complications [12]
References
Source material
Primary literature that informs this article.
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NEW TRENDS IN RESUSCITATION - PMC
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