Evolution of US Military Transfusion Support for Resuscitation of Trauma and Hemorrhagic Shock

Military conflicts create a dynamic medical environment in which the number of severe trauma cases is compressed in both time and space. In consequence, lessons are learned at a rapid pace. Because the military has an effective organizational structure at its disposal and the logistical capacity to rapidly disseminate new ideas, adoption of novel therapies and protective equipment occurs quickly. The recent conflicts in Iraq and Afghanistan are no exception: more than three dozen new clinical practice guidelines were implemented by the US Armed Forces, with attendant survival benefits, in response to observation and research by military physicians. Here we review the lessons learned by coalition medical personnel regarding resuscitation of severe trauma, integrating knowledge gained from massive transfusion, autopsies, and extensive review of medical records contained in the Joint Theater Trauma Registry. Changes in clinical care included the shift to resuscitation with 1:1:1 component therapy, use of fresh whole blood, and the application of both medical devices and pharmaceutical adjuncts to reduce bleeding. Future research will focus on emerging concepts regarding coagulopathy of trauma and evaluation of promising new blood products for far-forward resuscitation. New strategies aimed at reducing mortality on the battlefield will focus on resuscitation in the pre-hospital setting where hemorrhagic death continues to be a major challenge.