title: Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma.
abstract: The resuscitation of severely injured bleeding patients has evolved into a multi-modal strategy termed damage control resuscitation (DCR). This guideline evaluates several aspects of DCR including the role of massive transfusion (MT) protocols, the optimal target ratio of plasma (PLAS) and platelets (PLT) to red blood cells (RBC) during DCR, and the role of recombinant activated factor VII (rVIIa) and tranexamic acid (TXA).
  
  
  
  Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a subcommittee of the Practice Management Guidelines (PMG) Section of EAST conducted a systematic review using MEDLINE and EMBASE. Articles in English from1985 through 2015 were considered in evaluating four PICO questions relevant to DCR.
  
  
  
  A total of 37 studies were identified for analysis, of which 31 met criteria for quantitative meta-analysis. In these studies, mortality decreased with use of an MT/DCR protocol vs. no protocol (OR 0.61, 95% CI 0.43-0.87, p = 0.006) and with a high ratio of PLAS:RBC and PLT:RBC (relatively more PLAS and PLT) vs. a low ratio (OR 0.60, 95% CI 0.46-0.77, p < 0.0001; OR 0.44, 95% CI 0.28-0.71, p = 0.0003). Mortality and blood product use were no different with either rVIIa vs. no rVIIa or with TXA vs. no TXA.
  
  
  
  DCR can significantly improve outcomes in severely injured bleeding patients. After a review of the best available evidence, we recommend the use of a MT/DCR protocol in hospitals that manage such patients and recommend that the protocol target a high ratio of PLAS and PLT to RBC. This is best achieved by transfusing equal amounts of RBC, PLAS, and PLT during the early, empiric phase of resuscitation. We cannot recommend for or against the use of rVIIa based on the available evidence. Finally, we conditionally recommend the in-hospital use of TXA early in the management of severely injured bleeding patients.
authors.affiliation: From the Division of Traumatology, Surgical Critical Care & Emergency Surgery (J.W.C.), Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Imperial College Healthcare NHS Trust (M.A.K.), London, England; Department of Emergency Medicine (A.S.R.), Massachusetts General Hospital, Boston, MA; Harvard Medical School (A.S.R.), Boston, MA; Department of Surgery (M.J.C.), Denver Health Medical Center, Denver, CO; Department of Surgery (J.J.C.), Metrohealth Medical Center, Cleveland, OH; Division of Acute Care Surgery (B.A.C., E.E.F., J.B.H.), University of Texas Health Science Center at Houston, Houston, TX; Division of Vascular Surgery (J.J.D.), David Grant Medical Center, Travis Air Force Base, CA; Division of Trauma and Critical Care (K.I.), University of Southern California, Los Angeles, CA; General Surgery (C.J.R.), Uniformed Services University-Walter Reed Department of Surgery, Bethesda, MD; North Oaks Shock Trauma Program (J.C.D.), Hammond, LA.
authors.forename: Jeremy W
authors.initials: JW
authors.lastname: Cannon
authors.forename: Mansoor A
authors.initials: MA
authors.lastname: Khan
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: John J
authors.initials: JJ
authors.lastname: Como
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Dubose
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Kenji
authors.initials: K
authors.lastname: Inaba
authors.forename: Carlos J
authors.initials: CJ
authors.lastname: Rodriguez
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Juan C
authors.initials: JC
authors.lastname: Duchesne
mesh_terms: D000933:Antifibrinolytic Agents / Q000627:therapeutic use; D001772:Blood Cell Count; D001803:Blood Transfusion / Q000379:methods; D015942:Factor VIIa / Q000627:therapeutic use; D006470:Hemorrhage / Q000401:mortality / Q000628:therapy*; D006801:Humans; D011994:Recombinant Proteins / Q000627:therapeutic use; D012151:Resuscitation / Q000379:methods*; D014148:Tranexamic Acid / Q000627:therapeutic use; D015599:Trauma Severity Indices; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*
chemical_list: D000933:Antifibrinolytic Agents; D011994:Recombinant Proteins; D014148:Tranexamic Acid; C103587:recombinant FVIIa; D015942:Factor VIIa