The Second Battle: Equipping Austere Surgical Teams for Post-Resuscitation Coagulopathy

For 2 decades, U.S. combat casualty care relied on rapid evacuation, effectively outsourcing late-stage coagulopathy management to resource-laden specialists at Role 3 facilities and above. As we pivot to Large-Scale Combat Operations (LSCO) and the realities of Prolonged Casualty Care (PCC), this paradigm is no longer reliable. Our Austere Resuscitative Surgical Care (ARSC) assets, such as Forward Resuscitative and Surgical Detachments (FRSDs), will hold critically ill casualties for 24 hours or longer, making them responsible for managing the predictable, hypofibrinogenemic dilutional coagulopathy that occurs deep into massive transfusion protocols (MTP)-a condition for which their standard equipment sets lack the optimal treatment. This commentary argues for equipping ARSC assets with Fibrinogen Concentrate (FC) and proposes a pragmatic, evidence-based framework for its administration when advanced diagnostics are unavailable. The argument rests on 3 pillars. First, FC is clinically non-inferior to cryoprecipitate for treating acquired hypofibrinogenemia, as established by the FIBRES trial and confirmed by systematic reviews, while being logistically superior in every dimension critical to austere care: room-temperature storage, rapid reconstitution, standardized dosing, and a minimal logistical footprint. Second, the historical barriers to adoption-regulatory and safety concerns-have been eliminated by the 2024 FDA approval of FC for acquired fibrinogen deficiency and by large trials demonstrating no increased thromboembolic risk. Third, a synthesis of military blood-planning data with contemporary civilian transfusion research-including the largest analysis to date, nearly 50,000 massively transfused patients-demonstrates that a significant majority of combat surgical casualties will reach the transfusion volume threshold where fibrinogen supplementation is indicated, making FC a standard hemostatic tool rather than a niche rescue therapy. Standard MTPs already include cryoprecipitate in the second and subsequent batches at the Role 3. This commentary does not advocate for early empiric fibrinogen supplementation-a strategy recently tested in randomized trials that failed to demonstrate mortality benefit. It argues instead, in massively transfused patients who cannot be evacuated, to substitute the Role 3's threshold-triggered cryoprecipitate delivery with FC at ARSC platforms where cryoprecipitate is physically unavailable. This commentary proposes that FC administration in austere settings be guided by the standards that exist at the Role 3: transfusion volume triggers, validated clinical indicators of hypofibrinogenemia, and viscoelastic testing when available. FC warrants inclusion in the medical equipment sets for all ARSC assets to close a lethal capabilities gap.