Damage control surgery with the principles of expeditious control of hemorrhage and contamination, followed by predominant crystalloid resuscitation in the intensive care unit has saved the lives of many severely injured trauma patients. Unfortunately, crystalloid resuscitation has too often led to worsening of coagulopathy in the setting of vascular injury. The recent conflicts in Iraq and Afghanistan have created injured patients with severe vascular injury and massive soft tissue destruction creating early and profound coagulopathy associated with high rates of mortality. An alternative strategy, known as damage control resuscitation, with the principal resuscitation of a 1:1 ratio of packed red blood cells and fresh frozen plasma has been developed during these conflicts. This method is associated with decreased mortality and improved limb salvage in military and civilian trauma patients.