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Updated: Jul 16, 2025

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Debunking the lethal triad and delineating damage control surgery.

Fabrizio G Bonanno1

  • 1Department of Surgery, Polokwane Provincial Hospital Cnr Hospital, Polokwane, South Africa - Bonannogf@hotmail.com.

Minerva Surgery
|September 14, 2023
PubMed
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The lethal triad in trauma care is a misconception; only acidosis is a reliable indicator for damage control surgery (DCS). Understanding circulatory dynamics is key to reducing mortality in hemorrhagic shock.

Area of Science:

  • Trauma Surgery
  • Hemorrhagic Shock Management
  • Critical Care Medicine

Background:

  • The 'lethal triad' (acidosis, hypothermia, coagulopathy) has been incorrectly cited as the primary rationale for damage control surgery (DCS).
  • Existing literature overemphasizes the combined lethality of acidosis, hypothermia, and coagulopathy in trauma patients.

Purpose of the Study:

  • To re-evaluate the lethal triad's components and their direct impact on DCS indications.
  • To clarify the physiological cascade leading to mortality in hemorrhagic shock.
  • To establish a refined list of indications and optimal timing for DCS.

Main Methods:

  • Literature review and analysis of trauma resuscitation strategies.
  • Physiological modeling of macro and microcirculation dynamics in hemorrhagic shock.

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  • Correlation of specific physiological variables with patient outcomes.

    • Main Results:

    • Acidosis, not hypothermia or coagulopathy, is the sole lethal component of the traditional 'lethal triad' and a critical indicator for DCS.
    • Severe acidosis signifies profound hypoxemia and tissue hypoxia.
    • Hemorrhagic shock mortality is driven by complex circulatory dynamics, oxygen debt, and ischemia-reperfusion injury.

    Conclusions:

    • Damage control surgery (DCS) indications should be primarily guided by the presence of lethal acidosis.
    • Intervention strategies must focus on managing circulatory dynamics, oxygen delivery, and acidosis to improve outcomes.
    • A precise synoptic list for DCS indications and timing has been developed based on these findings.