Initial management of haemorrhagic war casualties: tactical priorities and innovative approaches in modern and future warfare

Abstract

Background

Haemorrhage remains the leading cause of preventable death in modern armed conflict, affecting both combatants and civilians. Recent conflicts—particularly the ongoing conflict in Ukraine— have highlighted the increasing complexity of battlefield injuries, characterised by hybrid warfare, disrupted evacuation chains, and delayed access to definitive surgical care. These realities challenge traditional trauma paradigms, such as the “Golden Hour” and demand adaptation of haemorrhage control and resuscitation strategies to austere environment.

Content

This narrative review synthesizes current practices and emerging innovations in the initial management of haemorrhagic shock in combat. Immediate haemorrhage control techniques—such as tourniquets, pelvic binders, direct vessel clamping, and external or endovascular aortic occlusion—are examined for their tactical relevance and impact on survival. The review underscores the role of haemostatic dressings and both topical and injectable haemostatic agents in controlling non-compressible bleeding. Damage control resuscitation centres on early administration of blood products in a 1:1:1 ratio or when available, low‑titer group O whole blood (LTOWB), combined with permissive hypotension and prevention of hypothermia. Whole blood and LTOWB are now routinely used by several armed forces, particularly the US and French armies, simplifying logistics and improving haemostatic efficacy during prehospital and tactical resuscitation. In cases of major haemorrhage, a transfusion protocol can be facilitated by novel products, such as leucocyte-depleted whole blood and freeze-dried blood products. Tranexamic acid, when administered within the first three hours after injury, halves mortality in massively transfused casualties, consistent with major international guidelines. Operational innovations address evacuation delays: forward damage-control surgery by lightweight Role 1/2 teams; drone delivery of blood components and medicines over distances from short range to>100 km, depending on platform capability and regulatory clearance; and prototype drone platforms for casualty evacuation (CASEVAC). Advanced technologies—such as closed-loop fluid systems, digital-twin physiology models, and AI-assisted triage—are poised to standardise care and reduce cognitive load for providers in austere settings.

Conclusion

The integration of haemorrhage control, targeted resuscitation, and logistical innovation defines the modern approach to managing war-related haemorrhagic shock. While challenges remain in evidence generation and field implementation, emerging practices—grounded in operational experience—are progressively improving survival. Ongoing investment in research, training, and technological adaptation will be essential to reducing preventable deaths on future battlefields.

Background

Haemorrhage remains the leading cause of preventable death among combatants and civilians affected by modern armed conflicts [1, 2]. Recent conflicts have underscored the evolving nature of battlefield injuries and the new challenges facing the traditional principles of trauma management [3, 4]. The ongoing conflict in Ukraine is a stark example of these difficulties and is characterised by hybrid warfare tactics, including artillery bombardments, drone strikes, thermobaric weaponry and cyber warfare [5]. These situations are often accompanied by significant delays in medical evacuation and deliberate targeting of medical infrastructure, challenging the conventional paradigm of the ‘Golden Hour’ in trauma care [6, 7]. The unique challenges of trauma care in conflict settings necessitate approaches distinct from those in civilian environments due to limited resources, extended evacuation times, and austere operational conditions. Unlike civilian trauma care systems, which generally provide rapid access to definitive care within a regionalised network, military care often occurs across multiple echelons separated by time and geography. The North Atlantic Treaty Organisation ((NATO) employs a tiered ‘Roles of Medical Care’ model. Role 1 delivers unit-level triage, pre-hospital emergency care and essential diagnostics. Role 2 (forward/basic/enhanced) adds damage-control resuscitation and surgery, with short-term post-operative critical care and limited holding, and—when enhanced—broader diagnostic and hospital capabilities. Role 3 provides deployable hospital-level specialist services, including intensive care. Role 4 delivers definitive treatment and rehabilitation in national facilities. This tiered structure enables escalation of care matched to operational complexity and casualty needs. In the field, initial haemorrhage control and damage control resuscitation are critical components of survival. Current best practices include the early application of tourniquets, haemostatic dressings and prehospital blood transfusion [8]. However, in large scale combat operations (LSCO), these interventions must be adapted for prolonged field care despite compromised logistical support [9]. Within combat teams, a single medic typically manages frontline medical care. Their equipment load, around 20–25 kg, balances essential lifesaving tools with mobility. This kit includes haemorrhage control items, airway management devices, intravenous fluids, and basic diagnostic equipment. Such preparation enables critical interventions under austere conditions, ensuring practical deployability of all described medical procedures. It is essential to develop advanced skills in the care of war wounded among non-physician prehospital care providers (particularly among combatants themselves). These personnel often perform essential roles in intensive care on the battlefield, despite their lack of formal training in intensive care. Developing their skills can have an impact on organ dysfunction.

This narrative review aims to summarise the current knowledge and recent advances in the management of combat casualties in haemorrhagic shock during modern warfare. Considering current geopolitical instability and growing concerns about LSCO, these lessons learned could be useful in future conflicts [10]. This review explores emerging strategies and innovations in the early management of haemorrhagic war casualties. These include advances in haemostatic resuscitation, surgical damage control at or near the frontlines, and logistical adaptations required by delayed evacuation. Finally, the review analyses the tactical constraints and technological opportunities that will shape future approaches to battlefield resuscitation in the hybrid environments of future warfare.

1. Immediate measures for haemorrhage control

The initial management of bleeding patients primarily relies on mechanical methods designed to control haemorrhage at the point of injury with techniques used for direct and indirect bleeding control, ranging from traditioneachal compression to aortic occlusion devices. These methods include peripheral and junctional tourniquets, pelvic binders, external aortic compression strategies, and emerging technologies targeting anatomically challenging wound sites. Table 1 summarises these devices according to their type, mechanism of action, cost, validation status, study population, and level of evidence.

Table 1.

Devices by type, principle, price, status, subjects tested and level of evidence

Type	Device	Principle	Status	Price ($)	Tested subjects	Level of proof
Topical hemostatic agents	QuikClot® Combat Gauze (Z-Medica, Wallingford, Connecticut, USA)	Mineral-based dressing with Kaolin	Marketed	75	Human	Clinical trial
	Celox® gauze (MedTrade Products, Johnstown, Colorado, USA)	Mineral-based dressing with Chitosan	Marketed	58	Human	Randomized control trial
	ChitoGauze® (Hemostasis LLC, Houston, Texas, USA)	Mineral-based dressing with Chitosan	Marketed	45	Human	Observational study
Injectable hemostatic agents	XStat® (RevMedx, Wilsonville, Oregon, USA)	Compressed mini-sponges	Marketed	91	Human	Therapeutic study, level V.
	ResQFoam™ (ResQFoam Inc., Redwood City, California, USA)	Two-component polymer	Prototype		Animal	Preclinical study (swine)
	Celox-A® (MedTrade Products, Johnstown, Colorado, USA)	Chitosan-based powder	Marketed	44	Human	Observational study
	LifeFoam™ (Medcura inc., Riverdale, Georgia, USA)	Injectable non thrombin foam	Prototype		Animal	Preclinical study (swine)
	Traumagel® (Cresilon, Brooklyn, New-York, USA)	Plant-based hydrogel	Prototype		Animal	Preclinical study
	Succor™ (Critical innovations LLC, Lawndale, California, USA)	Self-setting hydrogel	Prototype		Animal	Preclinical study
	Combat Application Tourniquet® (North American Rescue, Greer, South Carolina, USA)	Limb tourniquet	Marketed	34	Human	Retrospective study, prospective test
Tourniquets	SOFT-T® (Tactical Medical Solutions, Brooklyn Park, Minnesota, USA)	Limb tourniquet	Marketed	34	Human	Prospective, randomized, superiority trial
	Layperson Audiovisual Assist Tourniquet (InnoVital Systems Inc., Calverton, Maryland, USA)	Audiovisual assistance	Prototype		Human	Prospective, randomized, superiority trial
Junctional devices	Combat Ready Clamp® (Combat Medical Systems, Memphis, Tennessee, USA)	Mechanical clamp for inguinal hemorrhage	Marketed	399	Human	Case report
	Junctional Emergency Treatment Tool® (JETT) (Blue Sky Med Corp., Clearwater, Florida, USA)	Pneumatic/Mechanical compression	Marketed	360	Human	Observational study
	SAM® Junctional Tourniquet (SAM Medical Products, Wilsonville, Oregon, USA)	Mechanical pressure device	Marketed	350	Human	Observational study
Pelvic binders	SAM® Pelvic Sling II (SAM Medical Products, Wilsonville, Oregon, USA)	Circumferential pelvic stabilization	Marketed	83	Human	Observational study
	T-POD™ Pelvic Stabilization Device (Pyng Medical Corp., Richmond, British Columbia, Canada)	Circumferential pelvic stabilization	Marketed	140	Human	Observational study
Aortic compression	Abdominal Aortic and Junctional Tourniquet–Stabilized (AAJT-S) (Compression Works, Birmingham, Alabama, USA)	External aortic compression	Marketed	499	Human	Observational study
Aortic occlusion	ER-REBOA™ catheter (Prytime Medical Devices, Boerne, Texas, USA)	Complete aortic occlusion	Marketed	2000	Human	Observational study
	CODA® balloon catheter (Codman & Shurtleff, Raynham, Massachusetts, USA)	Complete aortic occlusion	Marketed	1199	Human	Observational study
	pREBOA-PRO™ (Prytime Medical Devices, Boerne, Texas, USA)	Partial occlusion devices	Marketed	499	Human	Case report

• A.Topical and injectable haemostatic agents

The introduction of topical and injectable haemostatic agents has produced a paradigm shift in the immediate management of haemorrhage, enabling rapid and targeted coagulation within seconds of application. Mineral-based dressings, such as QuikClot^® Combat Gauze (Z-Medica, Wallingford, Connecticut, USA), utilise kaolin to activate factor XII and initiate clotting [11]. In contrast, chitosan-impregnated products including Celox^® gauze (MedTrade Products, Johnstown, Colorado, USA) and ChitoGauze^® (Hemostasis LLC, Houston, Texas, USA) act by promoting fibrin polymerisation and platelet aggregation [12]. Both mechanisms allow rapid haemostasis, even in junctional regions where tourniquets are ineffective. Clinical and preclinical studies have demonstrated high efficacy across all three agents. QuikClot^® Combat Gauze, used in more than 400 documented clinical applications, has shown haemostatic success rates up to 95% and has not been associated with adverse events in its kaolin-based formulation [13, 14]. Similarly, Celox^® has demonstrated superior initial haemostasis compared to standard pressure dressings in a randomised controlled trial and consistently performs well in head-to-head comparisons [13]. ChitoGauze^® has also demonstrated efficacy in observational civilian and military settings, though evidence suggests its effectiveness may depend more heavily on correct application technique. Despite variations in study design and outcome reporting, existing literature indicates that Celox^®, QuikClot^® and ChitoGauze^® are comparably effective. QuikClot^® Combat Gauze is often preferred due to its ease of use, safety profile, and widespread field adoption by military and civilian providers alike. However, it is important to note that high-quality clinical evidence remains limited, and randomised controlled trials are still warranted. The US Committee on Tactical Combat Casualty Care (CoTCCC) currently recommends all three products for inclusion in individual first-aid kits, particularly for use in austere or battlefield conditions where rapid haemorrhage control is paramount [15]. According to the 2018 edition of the NATO Allied Joint Doctrine for Medical Support, the minimum content of individual first aid kits for all Allied forces must include a haemostatic agent or a haemostatic dressing [16, 17].

For non-compressible torso or truncal haemorrhage, injectable and expanding haemostatic agents provide a critical advantage. XStat^® (RevMedx, Wilsonville, Oregon, USA) is a syringe-based system that delivers approximately 92 compressed mini-sponges which expand upon contact with blood, exerting internal tamponade within 20 s. Each sponge is radio-opaque to facilitate radiographic localization prior to surgical retrieval. In coagulopathic porcine models with haemorrhage caused by sectioning of the axillary artery and vein, XStat^® has been shown to significantly reduce both total blood loss and time to haemostasis compared to conventional gauze packing. XStat^® is particularly effective in managing bleeding from narrow-entrance or junctional wounds caused by gunshots or stabbings—locations typically inaccessible to tourniquets [18]. However, it is contraindicated in intra-abdominal, intra-thoracic, or intra-pelvic bleeding. While easy to apply in the field, sponge removal is more complex and time-consuming than traditional packing, sometimes requiring wound extension. Radiographic clearance is essential to prevent retained foreign bodies.

Emerging technologies such as ResQFoam™ (ResQFoam Inc., Redwood City, California, USA) consist of a two-component polymer that solidifies into a conforming foam mass within the abdominopelvic cavity, creating internal tamponade [19]. In a controlled preclinical study using no coagulopathic swine, percutaneous injection of ResQFoam™ into the preperitoneal space improved survival relative to controls, and similar survival benefit was achieved compared with standard preperitoneal pelvic packing [20]. Similarly, chitosan-based powder applicators like Celox-A^® (MedTrade Products, Johnstown, Colorado, USA) have been developed for delivery into narrow wound tracts. These products rapidly accelerate clot formation in deep-penetrating injuries and are particularly useful when rapid haemorrhage control is required prior to surgical intervention [21]. LifeFoam^™ (Medcura inc., Riverdale, Georgia, USA), an injectable non thrombin foam in a syringe or spray form, composed of modified chitosan, is designed to stop bleeding during trauma, orthopaedic and pelvic surgery bleeding scenarios and improves survival in a lethal, closed-cavity swine model [22].

Among next generation haemostatic technologies, haemostatic hydrogels have emerged as promising solutions to address uncontrolled bleeding due to their unique properties, including biocompatibility, unable physical characteristics, and exceptional haemostatic capabilities [23]. Traumagel^® (Cresilon, Brooklyn, New-York, USA) is a plant-based hydrogel composed of sodium alginate and poly-N-acetyl-D-glucosamine. Delivered via prefilled syringe, it forms a rapid physical barrier at the bleeding site and promotes spontaneous clot formation without the need for manual pressure. However, Traumagel^® does not provide compressive haemostasis and has not yet been evaluated in rigorous pre-clinical or large-scale clinical studies for control of significant haemorrhage. Initially developed for battlefield use, Traumagel^® may be particularly suited to non-compressible torso or junctional haemorrhage, including gunshot wounds, offering fast, flowable application with minimal risk of tissue damage. Its ease of use and potential efficacy could make it a valuable adjunct in both civilian and military trauma care settings, particularly when conventional methods (e.g. gauze, tourniquet) are not feasible or carry limitations [24].

When applied promptly at the point of injury, these haemostatic agents significantly increase the likelihood of quickly achieving effective haemostasis. This rapid control of bleeding can reduce or delay the need for immediate surgical interventions such as debridement or exploratory surgery, thereby improving patient outcomes and stabilising the casualty for further care. They serve as indispensable adjuncts in modern battlefield trauma care, particularly in situations where evacuation may be delayed or surgical capability is limited. Nevertheless, the increased risk of infection associated with the use of local haemostatic solutions constitutes one of the main current limitations. The invasion of living tissue by micro-organisms can lead to bacterial infections, impede the healing process, cause serious damage to blood vessels and cells and lead to sepsis [25]. Consequently, a rigorous hygiene strategy, in addition to systematic antibiotic prophylaxis, must be initiated at the beginning of the treatment procedure [26]. In addition, some haemostatic materials are susceptible to bacterial contamination, particularly those that need to be stored for long periods or even reused. It is therefore advantageous to create haemostatic solutions with antimicrobial activity to counteract microbial interference [27]. For example, Succor™ (Critical innovations LLC, Lawndale, California, USA) is a novel, easy-to-use, self-setting hydrogel wound dressing for far forward care of traumatic wounds to prevent sepsis and treat local infection, while preserving tissue viability and promoting healing in austere environments and during prolonged field care [28]. There are several approaches to improving the antibacterial capability of haemostatic injection materials, such as incorporating antimicrobial components to inhibit bacterial growth or selecting materials with stronger inherent antibacterial properties. The development of antimicrobial materials effective against drug-resistant bacteria is a key area of future research in the field of haemostatic materials.

• B.Management of extremity and junctional haemorrhage

Immediate control of extremity haemorrhage remains a cornerstone of battlefield trauma care. The use of commercially designed limb tourniquets, such as the Combat Application Tourniquet^® (North American Rescue, Greer, South Carolina, USA) and the SOFT-T^® (Tactical Medical Solutions, Brooklyn Park, Minnesota, USA) has been widely adopted and consistently associated with improved survival in both combat and civilian settings [29, 30]. These devices have proven effective across various military environments, including in chemical, biological, radiological, and nuclear scenarios where protective gear is worn [31]. Tourniquet remains efficient in cold-weather operations. Recent conflicts have highlighted evolving challenges in tourniquet management [32]. Considering these constraints, Holcomb et al. advocate continued early tourniquet application in all cases of extremity haemorrhage [33]. They also stress the critical importance of early reassessment and conversion to alternative haemostatic techniques, such as distal repositioning or pressure dressings, as soon as it is tactically feasible. This approach minimises the risk of ischemic complications while maintaining haemostasis. Training in tourniquet reassessment and conversion is therefore increasingly recognised as a necessary complement to initial tourniquet application skills in modern combat medicine [34]. Complications associated with tourniquets, when applied correctly and for short periods, remain infrequent and typically involve transient neuropraxia rather than permanent disability. Nevertheless, the effectiveness of any tourniquet depends on correct placement, adequate pressure and frequent reassessment, particularly in austere environments and prolonged field care where surgical delays are inevitable. A recently developed tourniquet system, the Layperson Audiovisual Assist Tourniquet^® (InnoVital Systems Inc., Calverton, Maryland, USA) possesses features that instruct a non-professional user directly in proper tourniquet application [35]. Recent research findings suggest that the Layperson Audiovisual Assist Tourniquet has the potential to reduce the time taken to apply a tourniquet and increase the success rate of its application when compared to the standard combat application tourniquet. This is achieved by leveraging features that instruct and guide the user.

While limb tourniquets are highly effective for extremity haemorrhage, bleeding in junctional areas, such as the groin, axilla, or neck, requires alternative strategies. Specialised junctional devices have been developed, including the Combat Ready Clamp^® (Combat Medical Systems, Memphis, Tennessee, USA), the Junctional Emergency Treatment Tool^® (JETT) (Blue Sky Med Corp., Clearwater, Florida, USA), and the SAM^® Junctional Tourniquet (SAM Medical Products, Wilsonville, Oregon, USA). Although clinical data remain limited, case reports and animal models have shown successful arterial occlusion within 1–2 min [29, 36]. Application of junctional tourniquets requires specific training and should be considered a temporary measure pending definitive surgical control [32, 37, 38].

• C.Pelvic binders and immobilisation for long bone fractures

In any combat casualty with a mechanism suggestive of pelvic ring disruption (blast injury, high-speed vehicular trauma, or unexplained hemodynamic instability), a circumferential pelvic binder must be applied without delay [39]. Such fractures frequently result in life-threatening haemorrhage from presacral venous plexuses or branches of the internal iliac arteries, bleeding that is difficult to tamponade by external dressings alone. By encircling the pelvis at the level of the greater trochanters, a pelvic binder reduces the pelvic volume and mechanically approximates fracture fragments, thereby promoting internal tamponade of retro-peritoneal bleeds. Two commercial binders present the strongest biomechanical and clinical evidence base. The SAM^® Pelvic Sling II (SAM Medical Products, Wilsonville, Oregon, USA) utilises a force-controlled, one-piece design that has been proven to reliably restore pelvic ring integrity. The application process is rapid, taking less than 30 s, and the device can maintain a sustained tensile force more than 130 Newtons for a minimum of two hours. The T-POD™ Pelvic Stabilisation Device (Pyng Medical Corp., Richmond, British Columbia, Canada) has been shown to achieve effective volume reduction and stability in cadaver models [40]. The performance of both devices was found to exceed that of improvised binders (e.g. trousers or sheets) in terms of maintaining positioning during simulated casualty evacuations [41]. The application of binder is uniformly recommended in all hypotensive polytrauma casualties with suspected pelvic injury, given the low reliability of clinical examination alone in the prehospital setting [42]. Proper positioning over the greater trochanters is critical; misplacement over the iliac crest or abdomen compromises efficacy and may cause further injury. While prolonged use (> 6 h) may lead to soft tissue compromise or overtreatment of stable fractures, the immediate haemorrhage control benefit far outweighs these risks in the field. In current conflicts, pelvic binders have become indispensable tools in reducing pre-surgical mortality.

• D.Aortic compression

In cases where haemorrhage originates from the inguinal, pelvic, or abdominal regions, and standard dressings or limb tourniquets are not applicable, external aortic compression is a provisional measure to slow bleeding. The Abdominal Aortic and Junctional Tourniquet–Stabilised (AAJT-S) (Compression Works, Birmingham, Alabama, USA) is a wide, inflatable belt designed to occlude the aorta at either the supramesenteric (Zone 1) or infrarenal (Zone 3) level, depending on placement [43]. In a porcine junctional haemorrhage model, the AAJT-S achieved complete cessation of femoral arterial flow within seconds, with maintained occlusion for up to four hours in junctional sites and one hour in the mid-abdomen. Human data remain scarce, and operational deployment is limited [44]. The device demands precise placement and trained personnel, as excessive or prolonged inflation risks lower limb ischemia and visceral compression. In austere environments where such technology is unavailable, manual aortic compression using bi-manual pressure just above the umbilicus in the supine patient can provide transient perfusion control.

• E.Aortic occlusion

The endovascular balloon occlusion of the aorta (REBOA) represents a pivotal innovation for non-compressible truncal haemorrhage. In clinical practice, a balloon-tipped catheter is introduced via the common femoral artery and advanced fluoroscopically or ultrasound-guided into the aorta. Inflation in Zone 1 (descending thoracic aorta, above the diaphragm) results in the cessation of blood flow to abdominal and pelvic vessels. Conversely, deployment in Zone 3 (infrarenal aorta) targets the management of pelvic haemorrhage with a high degree of specificity. A few commercially available systems exist, including the ER-REBOA™ catheter (Prytime Medical Devices, Boerne, Texas, USA) and the CODA^® balloon catheter (Codman & Shurtleff, Raynham, Massachusetts, USA), designed for the purpose of rapid femoral access and controlled occlusion. The development of the pREBOA-PRO™ (Prytime Medical Devices, Boerne, Texas, USA) responds to the need for partial occlusion devices that offer improved tolerance and reduced ischemic complications [45]. Currently, it is the only Food and Drug Administration-approved device for partial REBOA and is increasingly used in the Ukrainian conflict, highlighting its relevance for Prolonged Field Care (PFC) and delayed evacuation scenarios.

Despite encouraging reports of improved hemodynamic stability and prolonged occlusion times in controlled settings, REBOA remains technically demanding, with arterial access as the principal limiting factor and complication source. Partial occlusion is gaining traction as a more physiologically favourable strategy, though its safe duration remains uncertain. It involves adjusting the device to allow for limited distal flow, balancing haemorrhage control with preservation of organ perfusion. Military-specific data remain limited, and outcomes in penetrating trauma are still debated, with some studies reporting increased morbidity and mortality when REBOA delays definitive haemorrhage control. A large 2025 observational study found that REBOA use in penetrating abdominal vascular injuries was associated with significantly worse outcomes, including increased mortality and complication rates, likely due to delayed definitive control and ischemic burden [46]. A recent multicentre randomised controlled trial did not demonstrate a mortality benefit in trauma patients with life-threatening torso haemorrhage, highlighting the limited and mixed evidence supporting REBOA in haemorrhagic shock management [47]. Current North Atlantic Treaty Organisation NATO-aligned military clinical practice guidelines restrict REBOA use to surgical teams trained in endovascular techniques, as an adjunct to damage-control resuscitation when immediate surgical access is unavailable [48, 49]. Ongoing research seeks to refine patient selection, determine safe occlusion thresholds, and develop standardised protocols. Meanwhile, training and interoperability remain critical challenges, prompting calls for shared metrics, improved simulation platforms, and harmonised doctrine among coalition partners.

• F.Direct vessel clamping

In cases of life-threatening haemorrhage, particularly from penetrating vascular injury to the trunk or periphery, direct vessel clamping remains a cornerstone of damage-control surgery. In war zones, clamping can be particularly useful in cases of traumatic amputation with persistent bleeding despite the use of several tourniquets. Emergency Resuscitative Thoracotomy (ERT) with descending aortic cross-clamping can save the lives of critically ill patients by providing temporary cerebral and coronary perfusion. ERT is a potentially lifesaving procedure when performed on the right patient at the right time, in accordance with established clinical practice guidelines such as those from Eastern Association for the Surgery of Trauma, Western Trauma, and the Joint Trauma System [50]. Its success depends on the availability of a minimal surgical platform and blood products, as well as appropriate patient selection based on injury mechanism and physiological status. Therefore, ERT is recommended to be performed only by specialist teams with operating surgical facilities (minimum Role 2) [51]. Although ERT remains controversial, with an overall survival of 27% at 24 h and 15% at 28 days, it has shown higher effectiveness in selected patients with refractory shock after penetrating trauma, where survival rates reached 64% and 47%, respectively [52].

By contrast, REBOA has been demonstrated to result in lower mortality rates when compared with resuscitative thoracotomy in specific patient groups. However, the evidence for this is mixed, and its benefits over standard care are not yet clearly established [53]. Clamping of peripheral vessels (e.g. the femoral or axillary artery) using DeBakey or Satinsky clamps can provide rapid haemorrhage control when the vessel is accessible. Digital occlusion or manual pressure can be used as interim measures before clamp placement. These techniques are particularly relevant in austere environments or in forward surgical units that are trained in damage-control interventions.

Once initial haemorrhage control has been achieved, the focus shifts to advanced resuscitation aimed at restoring perfusion, limiting or correcting coagulopathy, and enabling definitive haemostatic surgical intervention.

2. Advanced resuscitation strategies

• A.Crystalloid restriction

In addition to haemorrhage control, circulatory resuscitation in war casualties must adhere to the principles of damage control resuscitation (DCR) [54, 55]. In trauma-induced haemorrhagic shock, current resuscitation strategies emphasise the avoidance of large-volume crystalloid infusions due to their dilutional effects on haemostasis, risk of hypothermia, and potential for worsening trauma-induced coagulopathy. Crystalloids such as Ringer Lactate, are reserved for drug delivery or when transfusion is unavailable. This strategy improves survival, reduces coagulopathy, and aligns with current evidence against excessive fluid loading in early trauma care [56]. Artificial colloids are specifically avoided in tactical care due to their adverse effects on coagulation and renal function.

• B.Transfusion strategies

The cornerstone of haemorrhagic shock resuscitation is the early delivery of blood and blood components to restore oxygen-carrying capacity and coagulation function. In military settings, this involves balanced ratios of red blood cells, plasma, and platelets (typically 1:1:1), or low-titer group O whole blood (LTOWB), which provides all three in a single product [57]. In facilities with laboratory capability, the use of type-specific blood (including type-specific whole blood) is preferred to optimise compatibility; LTOWB remains essential in prehospital settings, in military treatment facilities without laboratory support, or when cross-match capacity is exceeded, offering a practical and effective option for early balanced resuscitation. Early observational studies supporting high plasma-to-red blood cells ratios were at risk from survival bias [58]; time-dependent analyses attenuate or remove the observed survival advantage and the PROPPR trial found no mortality difference between 1:1:1 and 1:1:2, though deaths from exsanguination at 24 h were lower with 1:1:1. Nevertheless, aggressive transfusion remains common, including prehospital. A Joint Trauma System review of combat support hospitals in Iraq and Afghanistan calculated a planning factor of eight whole-blood-equivalent (WBE) units for every casualty transfused, reflecting a mean 6.8 U WBE and frequent surges above ten units during mass-casualty events [59]. A companion analysis of 15,581 Role 2 admissions in the same theatres showed that 17% of casualties required blood and 11% met massive-transfusion criteria (≥ 3 U in the first hour), with occasional survivors receiving 50–80 U overall [60]. Conversely, front-line (Role 1) delivery remains the critical gap: in the Pre-hospital Trauma Registry, only 2% (28/1,357) of casualties received blood, simply because no product was available on scene [61]. The PAMPer trial showed a possible survival benefit from prehospital plasma transfusion [62]. However, later trials like COMBAT did not confirm this, likely due to shorter transport times [63]. The mechanism behind PAMPer’s findings remains unclear, suggesting selection biases and unbalanced groups in terms of the severity of haemorrhagic shock and coagulopathy. A recent Cochrane review found insufficient evidence to support routine prehospital transfusion [64]. The RePHILL trial found that prehospital transfusion of packed red RBC and freeze-dried plasma (FDP) did not result in a notable improvement in the prognosis of severely traumatised patients, as measured by a composite endpoint of mortality or decreased lactate clearance, when compared with resuscitation with 0.9% sodium chloride [65]. These results underscore the necessity for additional research to more precisely delineate the role of prehospital transfusion of labile blood products, particularly in strategies involving the use of whole blood, as well as in specific contexts such as austere environments, prolonged transport times, or certain patient subgroups such as those with penetrating trauma. Further studies should focus on specific contexts such as prolonged transport or combat settings where benefit might exist. The survival penalty is substantial. In Camp Bastion, Afghanistan, the implementation of pre-hospital blood product transfusion was associated with a 50% reduction in 24-hour mortality (from 19.6% to 8.2%) [66]. However, this association may have been influenced by confounding factors, including more extensive pre-hospital interventions, shorter transport times to definitive care, and differences in injury severity, which might also affect mortality outcomes. A subsequent re-analysis of Iraqi combat casualties further showed that approximately 30% of critically injured patients (NISS > 25) required blood transfusions, and that such transfusions, despite the duration of transport, independently improved patient outcomes [67]. The concept has been proven in austere environments by field programs [68, 69].

The French Military Medical Service pioneered prehospital use of freeze-dried plasma (PLYO) and warm whole blood kits during operations in the Sahel, achieving effective field stabilisation without adverse transfusion reactions [56, 70]. Riff et al. described the transfusion of low titer group O whole blood (LTOWB) by the French Military Medical Service during overseas operations in the Sahel-Saharan strip from 2021 to 2023. Forty units of LTOWB were transfused into 25 patients, enabling an early, high-ratio plasma-to-red blood cell transfusion and an early platelet transfusion for combat casualties [71]. Similarly, the Israel Defence Forces equipped frontline ambulances with LTOWB during the 2023 Gaza conflict. The results of this study revealed three neurologically intact survivors out of four administrations, and no adverse events were reported [72]. Recent experience confirms that 30% of severely injured casualties required transfusion, with median needs rising to 17 units in haemorrhagic shock [56]. In high-intensity warfare, where evacuation delays are common and casualties numerous, forward transfusion capacity is essential. Whole blood simplifies logistics, maintains coagulation function, and reduces mortality, and is now considered the first-line product for massive transfusion in combat zones, providing a critical source of coagulation factors during the prehospital phase [73]. Vein-to-vein transfusion, also known as the walking blood bank, is an interesting option in austere and military environments where conventional blood supplies are scarce. This method enables the immediate collection and transfusion of fresh whole blood from pre-screened donors within the unit, facilitating prompt haemostatic resuscitation. It reduces reliance on stored components and is particularly valuable during prolonged evacuations or mass casualty events [74]. Donors undergo ABO and Rh typing, infectious disease screening, and low-titer antibody testing prior to deployment to minimise transfusion risks. Collections follow sterile protocols to reduce contamination, including diversion of initial blood flow. Transfusions are performed with warm fresh whole blood immediately after collection, with refrigeration at 1–6 °C allowed for up to 24 h if needed. Rapid field compatibility testing supports timely administration. This approach optimizes haemostatic resuscitation with logistical simplicity and remains a fundamental pillar of the French battlefield transfusion strategy. Military forces now strive to deploy transfusion kits at the point of injury, including fresh whole blood from screened donors, group O red cells, AB freeze-dried plasma, and ideally cold platelets [75]. While O-negative blood is generally preferred for its universal compatibility, O-positive red cells or whole blood are acceptable for adult male casualties and, when O-negative is unavailable, for all casualties has gained acceptance in several military guidelines. This approach, however, remains a matter of ongoing because of RhD alloimmunization and transfusion reactions, which should be acknowledged when making transfusion decisions.

In addition to transfusions of whole blood or type O negative red blood cells, other solutions are emerging. One such innovation is artificial blood, which acts as an oxygen carrier [76]. Two oxygen carriers are currently in development: one using polymerised bovine haemoglobin (Hemopure^®) and another using purified polymerised human haemoglobin (ErythroMer^®). The potential of these substances to bridge the gap when conventional blood is unavailable or storage is impossible is also discussed. Both substances are supported by the U.S. Department of Defence [77]. Concurrently, coagulation support is undergoing a parallel evolution. In the United Kingdom and the United States, programs involving spray-dried (“atomised”) plasma are approaching licensure [78]. These programs offer a room-temperature alternative to lyophilised plasma, with reconstitution times of less than two minutes. First-in-human studies of ex-vivo cultured platelets (iPLAT1) and laboratory-grown red cells (RESTORE) have already demonstrated safety and post-transfusion survival [79, 80]. These findings suggest the possibility of donor-independent resupply options for austere or prolonged field care environments. Collectively, these innovations aim to reduce the logistic footprint and place a full haemostatic-and-oxygen-carrying capability on every forward evacuation platform. This would result in the closure of the " Role 1 transfusion gap”, which still costs preventable lives in high-intensity warfare. Beyond their initial use in combat, a rigorous evaluation of haemostatic agents is essential to ensure their safety and efficacy in broader clinical contexts. One such example is recombinant activated factor VII, which was introduced during the Gulf War as a haemostatic adjuvant. Ultimately, it failed to demonstrate any benefit in terms of mortality and was associated with an increased risk of arterial thrombosis [81].

• C.Blood pressure control

In modern battlefield medicine, blood-product resuscitation is typically conducted under permissive hypotension, with the objective of achieving a systolic blood pressure (SBP) of approximately 90 mm Hg for the time required to reach definitive haemostasis until definitive haemorrhage control is achieved [82–84]. This ceiling limits clot disruption, but the optimal pressure remains uncertain. When a traumatic brain or spinal-cord injury is present, the target must be raised to at least 100–110 mm Hg to safeguard cerebral perfusion, even at the cost of a modest increase in bleeding risk. Rixen and Siegel showed that the outcome is more strongly associated with the area under the pressure–time curve – a surrogate for cumulative oxygen debt – than with any single pressure value [85]. In this context, when evacuation is delayed, as is often the case in PFC scenarios, sustained deep hypotension has been shown to result in an increased incidence of multiorgan failure. Conversely, if systolic blood pressure is increased too soon, bleeding tends to recur. The medical personnel then proceed to titrate the pressure in incremental steps. This is in accordance with experimental and clinical data that link extended deep hypotension to cumulative oxygen debt and subsequent multiorgan failure [86–88].

Vasopressors should be considered as adjuncts, rather than substitutes. Low-dose norepinephrine (0.01–0.05 µg kg-1 min-1) is recommended once blood products are administered and mean arterial pressure continues to demonstrate a threat of falling below 50–55 mmHg [80]. The unavailability of syringe pumps for continuous administration in austere battlefield environments may lead to changes in practice, such as the use of iterative boluses of adrenaline. Recent evidence suggests that vasopressin may serve as an adjunct in the resuscitation of combat casualties experiencing haemorrhagic shock. A randomised clinical trial by Sims et al. demonstrated that low-dose arginine vasopressin supplementation significantly reduced the requirement for blood product transfusions in trauma patients with haemorrhagic shock, suggesting potential benefits in blood product conservation [89]. Complementing this, Rhee et al. have re-evaluated arginine vasopressin’s role in damage control resuscitation specifically for combat casualties, supporting its use for hemodynamic stabilisation [90]. Furthermore, Renberg et al. presented promising preclinical data on intramuscular vasopressin administration for early hemodynamic support in a porcine haemorrhagic shock model, highlighting its feasibility within prehospital settings [91]. These findings collectively underscore the evolving landscape for vasopressin as a haemodynamic adjunct in trauma care, warranting further investigation and potential integration into combat casualty resuscitation protocols. However, the caveat that it cannot compensate for an empty tank remains applicable. In practice, vasopressors should only be used as temporary adjuncts once blood products are being administered, with low-dose norepinephrine delivered by syringe pump where available, or small iterative boluses of adrenaline in austere settings.

• D.Early administration of tranexamic acid

Early tranexamic acid (TXA) administration reduces haemorrhage-related mortality, as shown in CRASH-2 and confirmed in the MATTERs study, where TXA halved mortality in massively transfused combat casualties (14% vs. 28%) without increasing thrombotic events [92]. TXA has shown a significant mortality benefit when administered within 3 h of injury in trauma patients. Administration beyond this three-hour window may not confer benefit and could potentially be harmful. This critical timing underscores the importance of early TXA administration in prehospital and combat casualty care to optimise outcomes. Military guidelines recommend 1 g intravenous or intraosseous as soon as possible, followed by 1 g during ongoing resuscitation [93]. However, in Ukraine, TXA remains rarely available prehospital, and early administration is often limited by lack of intravenous or intraosseous access [5]. A high dose of intramuscular TXA, showed to achieve effective serum concentrations in preclinical models, offers a promising alternative in austere or delayed-care settings [94, 95].

• E.Management of coagulopathy

Survival in haemorrhagic trauma is highly dependent on early recognition and correction of trauma-induced coagulopathy, the pivotal element of the classic “lethal triad” (coagulopathy, acidosis, hypothermia). In recent years, the concept of ionised hypocalcaemia as a fourth element, termed the “lethal diamond” hypothesis, has been proposed [96]. This hypothesis suggests that citrate-loaded blood products, catecholamine levels, and tissue hypoperfusion can result in calcium levels below the threshold required for thrombin generation and cardiac contractility [97]. The biological rationale is robust, yet validation is incomplete. While several studies have reported correlation between ionised calcium < 1.0 mmol/L and increased mortality, these are associative, and causality remains unproven [98, 99]. A 2025 multicenter cohort study of 2,141 transfused trauma patients found that adding hypocalcaemia did not enhance 24-hour mortality prediction compared with the triad alone (area under the curve 0.71 vs. 0.72, p = 0.26) [100]. This suggests that while hypocalcaemia is a relevant physiological marker, it may be a consequence rather than a driver of early death. Nonetheless, current recommendations advocate administering 1 g of intravenous calcium after the first unit of blood, and every 4–6 units, thereafter, targeting ionised calcium > 1.2 mmol/L. Calcium gluconate is preferred in peripheral access due to a lower risk of tissue injury [55].

Hypothermia impairs enzymatic coagulation processes below 34 °C and must be prevented from the earliest phase using passive and active warming strategies. Maintaining normothermia is therefore essential from the prehospital phase onward. Military guidelines recommend the use of thermal insulation, chemical heat packs, and warmed fluids or blood products (38–40 °C), particularly in cold operational environments such as Ukraine [101, 102]. However, any active heat source will invariably increase the casualty’s infrared signature. On sensor-saturated battlefields swarming with small drones, that extra heat can compromise concealment unless countermeasures (heat-reflective shells or purpose-built “infra-suppression” cloaks now fielded by Ukrainian units) are used concurrently [103]. It is therefore essential for medical personnel to balance the provision of thermal protection with the risk of detection, integrating warming devices with signature-management materials when the tactical situation demands it.

Other metabolic disturbances should also be anticipated and corrected where possible. Acidosis exacerbates coagulopathy and should be addressed primarily by optimising ventilation and perfusion to reverse the underlying cause. Although buffering agents such as bicarbonate have been used to correct severe acidosis, evidence from experimental and clinical studies suggests that bicarbonate therapy does not reliably reverse acidosis-induced coagulopathy and may not improve patient outcomes [104]. Therefore, correction should focus on preventing hypoxia and shock rather than routine bicarbonate administration, which remains controversial.

Together, these interventions aim to interrupt the pathophysiological cycle of lethal triad [71]. Their anticipation and correction are fundamental to the survival of haemorrhagic war casualties.

3. Perspectives and limits

High-intensity warfare and LSCO have changed the “golden hour” paradigm. In recent conflicts, such as those in Ukraine and the Sahel, medical evacuation routes have been observed to be subject to targeted attacks. Furthermore, the contestation of air superiority has been noted, and casualties have frequently been conveyed by road or rail, thereby extending the interval to surgical stabilisation [105]. These delays have driven the deployment of forward-surgical capability and prolonged field care strategies. Role 1 units provide immediate basic medical care and stabilisation at or near the point of injury but do not perform surgical interventions. Lightweight Role 2 surgical teams, by contrast, are equipped and staffed to perform damage control surgery close to the point of injury, bridging the gap before evacuation to higher-level medical facilities [106]. Gurney et al. propose a three-part “survival chain” in support of future military operations: point-of-injury care, casualty evacuation care and surgical care; all of them require critical care skills [107]. This model emphasises the necessity for seamless coordination and functionality of these interventions under combat conditions. Talley et al. propose that the chain can no longer rely primary on a doctrinal shift away from a system dependent on manpower towards a ‘human-technology’ architecture. In this architecture, sensors, artificial intelligence and robots automate the entire survival chain, from triage to evacuation, to preserve combat capability on a saturated and denied battlefield [108].

Unmanned Aerial Systems (UAS) have emerged as key assets in modern combat casualty care, particularly where traditional evacuation and supply routes are compromised by contested airspace, terrain, or enemy activity. Their most mature application lies in tactical medical logistics. Military trials have shown successful drone delivery of essential supplies such as packed red blood cells, freeze-dried plasma, tranexamic acid, and haemostatic agents to frontline units over distances exceeding 80–100 km, significantly reducing resupply delays in austere or besieged environments [109–111]. The next step is drone-assisted casualty evacuation (CASEVAC). Ukraine, a leader in this field, initiated the use of cargo drones to evacuate wounded soldiers in 2023 [112]. Other prototypes of heavy UASs have demonstrated their ability to autonomously transport casualties from hostile areas, such as urban ruins, chemical/biological exclusion zones, and high-risk front lines, without endangering medical personnel. For victims of haemorrhage, for whom every minute counts, rapid extraction by drone could reduce the time required for surgical stabilisation, particularly in areas lacking air superiority or access to rotary-wing aircraft. Additionally, during flight, onboard sensors function as telemedicine relays, transmitting vital signs to remote surgical teams [113].

The cornerstone of this evolution is continuous, passive data capture. High-fidelity data on the status of casualties, the use of resources, and the context of care would provide a foundation for the development of predictive models that could inform triage, evacuation procedures, the replenishment of resources, and the coordination of medical command-and-control systems [108]. Similarly, augmented reality–based training and Artificial intelligence (AI) -assisted triage tools could empower frontline non-specialist medical personnel to deliver advanced interventions, even in degraded or dispersed conditions [105]. Automation is also advancing within the resuscitation bay. Closed-loop resuscitation platforms that can titrate fluids, blood, and vasopressors based on real-time hemodynamic data have been shown to perform better than open-loop protocols in experimental models of haemorrhage [114]. However, these technologies remain largely experimental and are not yet widely implemented in clinical practice. When coupled with casualty-specific digital twins, they foreshadow personalised resuscitation pathways that are adaptable to austere settings and CASEVAC [115]. The development of additional AI decision aids is in progress, with the aim of identifying occult hemodynamic collapse, initiating transfusion protocols, and interpreting focused ultrasound. These tools are designed to reduce cognitive load and standardise haemorrhage control, even in situations where providers are under pressure [116]. The potential for these devices to function reliably in combat zones, particularly in prolonged field care or unmanned resuscitation units, suggests a viable solution for scenarios where resources are limited. Despite their present state of development, such systems are indicative of the future of automation and AI-assisted battlefield resuscitation and necessitate further field validation.

Despite these advances, important challenges remain. Much of the supporting evidence stems from observational studies, retrospective series, or animal models; randomised controlled trials in combat zones remain logistically and ethically challenging. Survivorship bias further complicates interpretation, as the most severely injured may never reach surgical care. Consequently, the efficacy and safety of certain interventions—such as REBOA in penetrating trauma or tourniquet use beyond six hours—are still not fully established. Even interventions with strong clinical support, such as early TXA administration, are not uniformly implemented due to limitations in prehospital access and delivery modalities. Operational constraints continue to challenge doctrine based on rapid evacuation. The “Golden Hour” is frequently exceeded, necessitating new models such as enhanced Role 1 teams capable of autonomous, prolonged field care. Innovations in logistics and training offer promising solutions [9, 78, 117].

However, the operational deployment of these innovations is constrained by cost, training requirements, and the absence of structured field validation. Most emerging technologies lack robust, military-specific outcome data. Future progress will depend on structured field trials and trauma registries aligned across NATO forces to evaluate these tools under realistic combat conditions.

A coordinated effort is needed to address remaining gaps. Key priorities include: (1) evaluating haemostatic strategies in prolonged field care; (2) expanding field-ready transfusion capacity, including freeze-dried and whole blood; (3) scaling access to TXA via intramuscular or auto-injector formats; and (4) validating automation with drone-based CASEVAC and AI-guided decision support through joint military exercises and multinational registries. Initiatives like NATO’s Vigorous Warrior 2024 represent critical platforms for standardising, testing, and integrating these capabilities [118]. Ultimately, reducing preventable deaths from haemorrhage in future conflicts will require not only tactical innovation but also strategic alignment of training, doctrine, and evidence generation. Effective management of war-related haemorrhage relies on rapid, protocolised care. To prepare frontline providers, recent innovations in simulation and immersive training are redefining military medical education [105, 119, 120]. Augmented reality enables remote instruction in procedures like tourniquet placement, chest decompression, and REBOA, with interactive overlays and performance feedback. In resource-limited or dispersed environments, this allows continuous skills maintenance [121].

The development of combat medical capabilities must be based on a triptych of skills: technical skills (knowledge of procedures and equipment); non-technical skills (communication, leadership and situational awareness); and tactical skills (knowledge of the operational environment and threat context) [122]. This integrated approach is now considered essential for deploying advanced surgical teams and managing mass casualty incidents. Training programs must incorporate crew resource management, stress inoculation, and mission-specific scenarios to ensure effectiveness in high-threat, complex situations [123].

Figure 1 summarises the key domains and research priorities identified for the future management of haemorrhagic war casualties, highlighting current gaps and areas requiring further validation.

Fig. 1.

Research priorities in haemorrhagic war casualty care. This Figure was made with Perplexity AI REBOA, Resuscitative Endovascular Balloon Occlusion of the Aorta; Role 1, first echelon of medical support; CASEVAC, casualty evacuation; AI, artificial intelligence; AR, augmented reality; RCTs, randomized controlled trials

Conclusion

The initial management of haemorrhagic war casualties is undergoing a profound evolution, driven by the realities of LSCO, prolonged evacuation timelines, and increasingly complex injury patterns. Contemporary practices are rooted in damage control resuscitation principles: early haemorrhage control, early transfusion, and correction of coagulopathy and hypothermia. They are increasingly supported by innovations in logistics, technology, and field training. While many interventions have demonstrated survival benefits, significant gaps remain in evidence generation and implementation. Techniques such as prolonged tourniquet use, and drone-assisted evacuation require structured validation in combat-relevant contexts. Emerging technologies, including automation with drones and AI, and deployable blood products, hold considerable promise but must be rigorously evaluated before widespread adoption. In this evolving landscape, future progress depends on a coordinated effort to align doctrine, research, and operational feedback. Field trials, multinational trauma registries, and inter-theatre collaboration will be key to transforming innovation into standardised, effective care. Ultimately, reducing preventable haemorrhagic deaths in war will require not only better tools, but also sustained investment in training, logistics, and data-driven adaptation.

Abbreviations

AI

Artificial intelligence

CASEVAC

Casualty evacuation

DCR

Damage control resuscitation

ERT

Emergency resuscitative thoracotomy

LTOWB

Low titer group O whole blood

NATO

North atlantic treaty organisation

REBOA

Resuscitative endovascular balloon occlusion of the aorta

TXA

Tranexamic acid

UAV

Unmanned aerial vehicle

UAS

Unmanned aerial system

Author contributions

NL conceived the review and supervised the project. AJ and NL performed the literature review. AJ drafted the first version of the manuscript. All authors contributed to the writing, critically revised the manuscript for important intellectual content, and approved the final version.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

Not applicable. No datasets were generated or analysed for this review. All information discussed is available in the published literature cited in the References.

Declarations

Ethics approval and consent to participate

Not applicable. This article is a narrative review and does not contain any studies with human participants or animals performed by any of the authors.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Disclaimers

The opinions or assertions expressed herein are the private views of the authors and are not to be considered as reflecting the official views of the French Military Medical Service.