Delayed Resuscitation in Hemorrhagic Shock Due to Severe Injuries of the Torso in Low-resource Facilities of Latin America.

Background / Introduction

Trauma remains a leading cause of mortality worldwide, particularly among young and economically productive populations, generating a disproportionate burden in terms of years of life lost, disability, and healthcare expenditures. Hemorrhagic shock is the most common cause of preventable death following trauma, especially within the first hours after injury. Despite advances in trauma systems and critical care, early mortality due to uncontrolled bleeding continues to pose a major clinical challenge.

Traditional resuscitation strategies have emphasized aggressive early fluid administration aimed at restoring normotension. However, growing evidence suggests that this approach may be physiologically detrimental in the setting of uncontrolled hemorrhage. Rapid volume expansion can dislodge forming clots, dilute coagulation factors, exacerbate acidosis, and contribute to the development of trauma-induced coagulopathy. These mechanisms are closely associated with the so-called "lethal triad" of trauma: hypothermia, acidosis, and coagulopathy, which significantly increases mortality risk.

In response to these concerns, the concept of delayed resuscitation, also referred to as permissive hypotension, has emerged as a damage control strategy. This approach aims to limit fluid administration until hemorrhage control is achieved, maintaining a lower-than-normal blood pressure sufficient for minimal organ perfusion while avoiding exacerbation of bleeding. Experimental models and clinical studies have suggested potential benefits, including reduced blood loss, lower transfusion requirements, and improved survival in selected patient populations.

However, the current body of evidence presents important limitations. Many studies have been conducted in high-resource settings with well-developed trauma systems, rapid surgical access, and availability of blood products. Furthermore, heterogeneity in study design, patient populations, injury patterns, and resuscitation protocols limits the generalizability of findings. Importantly, patients with traumatic brain injury, elderly individuals, and those with significant comorbidities may respond differently to hypotensive strategies, raising concerns regarding safety and applicability.