Introduction

There are few areas in medicine which have changed as much in the past ten to 20 years as the management of the severely traumatised patient, driven for the most part by the complexity and severity of the trauma in recent military conflicts. Few patients offer a greater challenge than the critically injured patient. The acuity and uncertainty of the extent of the injuries require the anaesthetist to be both vigilant and methodical as the case progresses. Rapid changes in the patient’s condition occur commonly and constant communication between anaesthetist, surgeon and the rest of the team is vital. The anaesthetist should take an active lead in the operating theatre, in combination with the senior surgeon present, as he/she has the greatest situational awareness and needs to be aware of the resources at his/her disposal. Therefore, the traditional metaphorical ‘blood brain barrier’ or physical drape that still exists between the surgeon and anaesthetist in some elective surgery has been replaced by constant communication, supporting an integrated damage-control philosophy. There are three central tenets to the damage-control philosophy: permissive hypotension, damage-control or haemostatic resuscitation, and damage-control surgery.

The damage-control philosophy was initially conceived as a surgical approach to the multiply injured patient when it was realised that such patients lacked the physiological reserve to survive complex reconstructive surgery and restoration of anatomy. Damage-control surgery is confined to that surgery which is necessary to control haemorrhage and limit contamination. Temporary cavity closure further abbreviates the surgery and the patient is then normalised physiologically in the intensive care unit before definitive anatomical repair 24 to 72 hours later. However, such an approach to a severely traumatised patient cannot be used in isolation. Haemostatic resuscitation and permissive hypotension also contribute to the philosophy of damage control in an effort to limit the development of the ‘lethal triad’. An institutional massive transfusion protocol for trauma is also required.