Damage Control Resuscitation for Severe Traumatic Brain Injury

Life-threatening hemorrhage (LTH) and traumatic brain injury (TBI) remain the leading causes of preventable deaths in trauma. Damage control resuscitation (DCR) has become a highly popular treatment strategy for LTH. Although such a management strategy is well-established for LTH, alternative treatment strategies and management considerations should be applied to patients with concurrent severe TBI. As such, DCR prioritizing hypotensive resuscitation may be contraindicated in this setting. The presence of severe TBI, in addition to LTH, presents a unique clinical scenario in which providers should be well-versed. Severe TBI alone can contribute to widespread impairment of hemostasis, endothelial function, coagulation, and immune function. In the setting of LTH, severe TBI can even contribute to potentiation of the lethal triad-acidosis, coagulopathy, and hypothermia-in trauma. To improve patient outcomes, pre- and in-hospital care of patients with LTH and severe TBI requires avoiding hypoxia and hypotension to minimize secondary brain injury and optimizing intracranial hemodynamics. Although several resuscitative fluids and strategies exist, there is no consensus for the optimal resuscitative fluid for patients with severe TBI and LTH. Each strategy has its own benefits and limitations, which providers should consider. In recent years, several novel treatment agents, including valproic acid (VPA), have demonstrated great promise in improving outcomes in models of concurrent LTH and severe TBI. However, further testing of these strategies and exploration of additional treatment options for patients with LTH and severe TBI are warranted.