We were pleased to read the Clinical Focus Review by Richards et al., “Damage Control Resuscitation in Traumatic Hemorrhage: It Is More Than Fixing the Holes and Filling the Tank”  in the March 2024 issue of Anesthesiology. This review is one of the most succinct yet comprehensive discussions of evidence-based trauma resuscitation that we have encountered. As military anesthesiologists, this topic is of particular interest to us. We feel that this will serve as a valuable reference for service members deployed to combat zones. We also look forward to using this article to discuss resuscitation with our residents as a teaching guide.

We do, however, find the term “damage control resuscitation” to be misleading in this context. The U.S. Military has used this term for decades, and its use by Richards et al. here invites confusion. In 2006, the United States Army published clinical practice guidelines for damage control resuscitation.  This term developed as an extension of the concept of damage control surgery, which emphasized hemorrhage control, decontamination, and correction of major physiologic derangements before definitive repair.  Damage control resuscitation practice guidelines recommended a higher than traditional fresh frozen plasma: packed red blood cell transfusion ratio and restrictive crystalloid use. These practices likely contributed to the decrease in trauma mortality during the wars of the last 2 decades.  The concepts of damage control resuscitation were further developed in the military when the Defense Health Agency’s (Falls Church, Virginia) Joint Trauma System advocated for the use of whole blood when available. Among allied military partners, whole blood has similarly been recommended for use.

Resuscitation is the act of reviving the near-dead to a state of hemodynamic stability. Generally, this involves the correction of physiologic abnormalities, including hemorrhage, acidosis, hypothermia, coagulopathy, and electrolyte disturbances. While patients with significant trauma often require rapid, large-volume resuscitation, they are hardly the only patients in need of such resuscitation. All of the techniques and considerations that are described by Richards et al. are likely valid for most surgical patient populations, not just those who undergo traumatic hemorrhage. Our concern is that the damage control resuscitation label may imply that these well-described fundamentals of comprehensive resuscitation are solely applicable to the trauma patient population, and do not necessarily apply to other surgical patients requiring similar resuscitation.

Ultimately, we feel the concept of damage control resuscitation is misleading because there is no “damage control” aspect of the resuscitation, unlike with damage control surgery. No amount of damage control resuscitation will fix or correct damage, whether caused by trauma or otherwise. It is a way to buy time for definitive treatment. Furthermore, “damage” is term not historically applied to people. Structures are damaged; machines are damaged; networks are damaged. Humans are injured. Better terms may include “comprehensive,” “goal-directed,” or “balanced” resuscitation, all of which highlight the broader approach to correcting physiologic derangements than simply transfusing red cells.

Despite our concerns with the terminology used by Richards et al., we would again like to emphasize that their article will serve as a foundational document for anesthesiologists who are deploying into harm’s way, and seek to have the most up-to-date knowledge on how to care for our service members. We would press the authors to consider the use of more inclusive language to ensure that these lessons are applied outside of the trauma-specific patient population as well.