The management of patients requiring a damage control approach taxes the abilities of the best equipped trauma center. These patients present with severe metabolic abnormalities, most notably characterized by a deadly triad of hypothermia, coagulopathy, and acidosis. Using volumetric, oxymetric pulmonary artery catheters, hypothermia and any ongoing cardiovascular abnormalities can be identified quickly and treatment can be monitored. External, forced air rewarming is a valuable technique in treating the patient with hypothermia, as are more invasive modalities, including body cavity lavage. Although there is no shotgun approach to blood component transfusion therapy, the coagulopathy shown by these patients has a time course that is more rapid than stat laboratories can presently keep up with. Given the fulminant nature of this coagulopathy, the authors feel justified in empirically initiating platelet and plasma or cryoprecipitate transfusion on identification of visible coagulopathy. The willingness of trauma surgeons to push the envelope in treating these most severely afflicted patients has allowed patients who once would have certainly died to lead meaningful lives.