Damage-Control Resuscitation
Objective: Resuscitate bleeding trauma with restraint — stop the bleed, restrict crystalloid, prevent hypothermia, and never run “permissive hypotension” on a brain injury.
Why This Is Hard
Two liters of saline in a bleeder dilutes clot, drops temperature, and pops the plug. ACS/AAST damage-control resuscitation and NAEMSP trauma statements: early hemorrhage control, hypotensive/restrictive resuscitation until bleeding is controlled, balanced blood products when available, and hypothermia prevention. The exception that kills if you copy-paste: TBI does not get permissive hypotension (see TBI).
- Bleed first — TQ, pack, binder, seal
- Crystalloid is a bridge, not a treatment
- Warm — lethal diamond: hypothermia, acidosis, coagulopathy, hypocalcemia
- Head injury + shock → do not “keep them at 80 systolic” on purpose
Permissive Hypotension — With Brakes
- Teaching idea: in bleeding adults without TBI, enough volume to keep a radial pulse / mentation / protocol SBP floor (often around 80–90 mm Hg in classic education) until blood and a surgeon. Exact numbers are protocol-owned.
- ACS 2021 field triage still treats hypotension as a highest-level trauma-center finding. Restrictive fluids is not “ignore shock.”
- Do not apply this to suspected severe TBI or to kids without a pediatric protocol that says so. The brain needs pressure.
What to Give
- Blood products if your system carries them (whole blood or balanced components). That is DCR. Saline is not.
- TXA after LSIs, shock, ≤3 hours — see TXA.
- NAEMSP: routine prehospital vasopressors for traumatic hemorrhagic shock are not supported and may harm. Pressors are not a substitute for volume and a hole-closer. Neurogenic shock is a different conversation.
- Keep them warm: wet clothes off, blankets, heat in the box. Cold blood does not clot.
Field Pitfalls
- Wide-open saline on a GSW while the TQ is still in the bag.
- Running a “keep them dry” SBP of 80 on a helmeted motorcycle TBI.
- Forgetting the pelvic binder because you are busy with a line.
Practice
60-second drill
Partner: (1) stab wound, BP 78, no TBI; (2) same BP, blown pupil after a fall. Fluid/BP philosophy in one sentence each, plus the first mechanical move.
Related: Massive Hemorrhage, TBI, Pelvic Binder.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AAST 2024 damage-control resuscitation guidance — hemorrhage control, hypotensive/restrictive crystalloid until bleeding is controlled, balanced blood products when available
- NAEMSP: Vasopressors in Trauma (2024) — routine prehospital vasopressors for traumatic hemorrhagic shock are not supported and may harm
- BTF 2023 prehospital TBI — avoid hypotension in TBI; do not copy permissive hypotension onto a head
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.