Abstract
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy—especially in austere or challenging environments—is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.
Highlights
Resuscitation in far-forward combat zones has its roots in the early 19th century based on insights gained during the disastrous French invasion of Russia during the Napoleonic wars
Type of Study and Setting as an adjunct to platelet counts and hematocrit was more predictive of blood transfusion than PT, aPTT, and INR together
At the Battalion Aid Station where resuscitation is continued, it is crucial that viscoelastic hemostatic assay (VHA) be used as guide blood products as it would be done at any civilian hospital regardless of size
Summary
Resuscitation in far-forward combat zones has its roots in the early 19th century based on insights gained during the disastrous French invasion of Russia during the Napoleonic wars. The difficulty of sourcing and storing sufficient quantities of WB and blood products, as well as the high risk of hepatitis from transfusions, gradually led to an emphasis on crystalloid infusions to achieve targeted blood pressures in combat resuscitations during the Vietnam War [4] This technique was prone to failure, largely due to the poor understanding of the coagulopathy of traumatic blood loss. In 2008, Plotkin et al published a landmark study that detailed how viscoelastic hemostatic assays (VHAs) had been a better guide to predict coagulopathy and the need for massive transfusion (MT) of injured soldiers in a combat hospital compared to conventional coagulation assays (CCAs) (e.g., aPTT, PT/INR, fibrinogen, and platelet count) [15] This was the first study demonstrating the feasibility of using point-of-care (POC) VHAs in the far-forward combat environment and suggested that WB protocols may be augmented by individualized and goal-directed blood-component therapy (BCT). MT, massive transfusion; rotational therapy; CCAs, conventional coagulation assays; ROTEM, thromboelastometry; TEG, thromboelastography; r-TEG, rapid thromboelastography. rotational thromboelastometry; TEG, thromboelastography; r-TEG, rapid thromboelastography
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