Damage-Control Resuscitation

Why this matters

A large saline infusion in a patient who is still bleeding dilutes clotting factors, drops temperature, and can break a clot that is just forming. Damage-control resuscitation means four things. Stop bleeding early. Limit crystalloid until bleeding is controlled. Give balanced blood products when your service carries them. Prevent hypothermia.

Do not copy a low blood-pressure target onto a traumatic brain injury. The brain needs pressure. See the TBI lesson.

Clinical sequence

1. Stop the bleeding first. Use a tourniquet, packing, and a chest seal as indicated. Apply a pelvic binder only if your protocol still uses one.
2. Treat crystalloid as a bridge. Do not give large volumes of saline to a patient who is still bleeding.
3. Keep the patient warm. The lethal diamond is hypothermia, acidosis, coagulopathy (blood that will not clot), and hypocalcemia (low calcium).
4. If the patient has a head injury and shock, do not run a low blood pressure on purpose. The brain needs pressure.

Permissive Hypotension — With Brakes

• The teaching idea, for a bleeding adult without traumatic brain injury, is enough volume to keep a radial pulse, a clear mental status, or the lowest systolic pressure your protocol names, until blood and a surgeon are available. This page does not set a blood-pressure number.
• ACS 2021 field triage still treats hypotension as a reason for the highest-level trauma center. Limiting crystalloid is not the same as ignoring shock.
• Do not use permissive hypotension for suspected severe traumatic brain injury, or for children, unless a pediatric protocol specifically says so. The brain needs pressure.

How You Resuscitate

• Blood products, if your system carries them, are damage-control resuscitation. That means whole blood or balanced components. Saline is not a substitute. If you do not carry blood, you cannot invent it on scene.
• Tranexamic acid (TXA) comes after life-saving bleeding control, in a patient with clinical shock, and within 3 hours of injury. See the TXA lesson. This site does not publish a milligram recipe.
• NAEMSP teaching: routine prehospital vasopressors for traumatic hemorrhagic shock are not supported and may harm. A vasopressor does not replace volume or closing the bleeding site. Neurogenic shock is a different problem.
• Keep the patient warm. Remove wet clothes, use blankets, and turn the heat up in the ambulance.

Common errors

• Running saline as fast as it will go on a gunshot wound while the tourniquet is still in the bag.
• Holding a systolic pressure around 80 on purpose in a helmeted motorcycle patient with a brain injury.
• Treating a pelvic binder as the whole shock plan while an external wound is still bleeding.

Practice

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; your protocol decides
• 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 injury