Damage control resuscitation in resource-diverse settings: a survey-based comparison of trauma care practices worldwide

Purpose:  Trauma is a major global cause of death, with uncontrolled hemorrhage as its leading preventable cause. Damage control resuscitation (DCR) is a cornerstone strategy for hemorrhagic shock, yet implementation varies by resource availability. This study compared DCR practices between high-income countries (HICs) and low- and middle-income countries (LMICs), predominantly represented by institutions from Latin America, particularly Brazil.

Methods:  A cross-sectional survey of trauma care providers was conducted between 2024 and 2025, assessing DCR practices, resuscitation strategies, and adjunctive therapies. Data from a Brazilian national survey were incorporated into the LMIC cohort. Countries were classified using World Bank 2024 income criteria, and comparisons were analyzed using hierarchical logistic regression with adjustment for multiple comparisons.

Results:  Massive transfusion protocol availability result was significantly lower in LMICs than in HICs (47.4 vs. 89.1%; OR = 0.11, 95%CI 0.02–0.62; p(BH) < 0.001). LMICs also had reduced availability of fresh frozen plasma (OR = 0.04; p(BH) = 0.035), balanced crystalloids (OR = 0.21; p(BH) < 0.001), viscoelastic coagulation monitoring (TEG/ROTEM; OR = 0.04; p(BH) 0.001), prothrombin complex concentrate (OR = 0.01; p(BH) < 0.001), fibrinogen concentrate (OR = 0.10; p(BH) < 0.001), rapid infusers (OR = 0.04; p(BH) < 0.001), invasive temperature monitoring (OR = 0.02; p(BH) < 0.001), calcium replacement (OR = 0.17; p(BH) = 0.002), and active rewarming systems (OR = 0.21; p(BH) = 0.035). Whole blood use was lower in LMICs (5.8 vs. 17.4%) but did not reach statistical significance in the primary model (OR = 0.55, 95%CI 0.12–2.45). Tranexamic acid availability was nearly universal and did not differ between settings (96.1 vs. 97.8%).

Conclusion:  Although DCR principles are widely recognized, substantial disparities persist in access to critical resuscitation resources across income settings.

Key words
Blood Transfusion; Trauma Centers; Multiple Trauma; Shock, Hemorrhagic; Resuscitation