Hemorrhagic Resuscitation Guided by Viscoelastography in Far-Forward Combat and Austere Civilian Environments: Goal-Directed Whole-Blood and Blood-Component Therapy Far from the Trauma Center

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.

Advances in trauma care to save lives from traumatic injury: A narrative review

“…In this registry analysis, mortality was increased if TIC developed regardless of trauma severity 48 . Since there is no score to assess complete coagulation chain and predict massive transfusion in trauma management, Viscoelastic hemostatic assays (VHA) have been proposed for many years to provide personalized management of TIC 49 . ThromboElastoGraphy and ROTational thromboElastoMetry use (TEG/ROTEM) reduces the total amount of blood product transfused, with more fibrinogen and plasma replacement 50 .…”

“…48 Since there is no score to assess complete coagulation chain and predict massive transfusion in trauma management, Viscoelastic hemostatic assays (VHA) have been proposed for many years to provide personalized management of TIC. 49 ThromboElastoGraphy and ROTational thromboElastoMetry use (TEG/ROTEM) reduces the total amount of blood product transfused, with more fibrinogen and plasma replacement. 50 Viscoelastic hemostatic assays are progressively becoming standard of care for the early diagnosis of TIC, including for coagulation activation evaluation, clot strength and fibrinolysis.…”

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

“…47 The resurgence of viscoelastic testing has allowed us to be more precise and individualized in the management of coagulopathy after trauma. [48][49][50][51] Although conventional coagulation tests (e.g., prothrombin time/INR, fibrinogen, platelet count) provide a limited understanding of an individual patient's coagulation status, viscoelastic tests provide a more comprehensive view and demonstrate disorders of clot initiation, propagation, and lysis. These complex changes in coagulopathy following injury are driven by the endothelial changes, platelet dysfunction, impaired thrombin generation, depletion of fibrinogen, and activation of fibrinolysis.…”