THOR Position Paper on Remote Damage Control Resuscitation: Definitions, Current Practice and Knowledge Gaps

The Trauma Hemostasis and Oxygenation Research (THOR) Network held its third annual Remote Damage Control Resuscitation (RDCR) Symposium in June of 2013 at Solstrand Hotel, near Bergen Norway. THOR is a multidisciplinary group of clinical, translational and basic investigators with a common interest in improving outcomes and safety in patients with severe traumatic injury. The Network’s mission is to reduce the morbidity and mortality from traumatic hemorrhagic shock, in the pre-hospital phase of resuscitation through education, training and research. RDCR has been defined as the pre-hospital application of Damage Control Resuscitation (DCR) concepts (1, 2). DCR principles include: compressible hemorrhage control; hypotensive resuscitation; rapid surgical control of bleeding; avoidance of the overuse of crystalloids and colloids, prevention or correction of acidosis, hypothermia, and hypocalcemia; and hemostatic resuscitation (early use of a balanced amount of red blood cells (RBCs), plasma, and platelets).(3) The term RDCR was first published by Gerhardt and colleagues from the United States Army Institute of Surgical Research and since been promoted by the THOR Network.(1, 2, 4) The initial definition of DCR, by Holcomb and colleagues, states “DCR addresses the entire lethal triad immediately upon admission to a combat hospital”.(3) Others have promoted expanding the definition to include care from the point of injury.(5) Since early identification and treatment of hemorrhagic shock may improve outcomes, we contend that the distinction between RDCR and DCR is an important one since there are differences in capabilities, and in some cases optimal management strategies between pre-hospital and in-hospital care. These differences may include availability of blood products and monitoring capabilities, as well as the lack of evidence to support the use of hypotensive resuscitation strategies for delayed or prolonged evacuation and the associated risks with airway management for casualties in hemorrhagic shock. The debate over the appropriate term for pre-hospital resuscitation concepts and others discussed at the RDCR Symposium’s in the past has motivated the leadership to produce a position paper. The aim of this paper is to offer standardized definitions of key components of RDCR by which one could truly compare techniques, strategies, products/devices and outcomes; define the currently acceptable ranges of practice (from soldiers to medics to physicians); and identify knowledge gaps in RDCR that should be addressed with future research.