Trauma critical care in trauma patients during large-scale combat operations: An unresolved capability gap

Future large-scale combat operations (LSCO) will invalidate core assumptions of modern trauma care. Contested movement, disrupted logistics, and prolonged or denied evacuation will make timely surgical access and fully resourced critical care the exception rather than the rule. While recent conflicts optimized early hemorrhage control, the capacity to sustain critically injured patients in LSCO environments remains poorly defined. In LSCO, trauma care shifts from episodic intervention to prolonged system endurance. Injuries routinely survivable in resource-rich settings will become functionally non-survivable under these conditions. Future combat casualty survival will depend less on maximal capability than what care can be sustained under constant constraint. Without austere-adapted critical care standards, doctrinal alignment, and operationally embedded research, the gains of modern combat casualty care will not translate to the future battlefields where they are needed the most. This review synthesizes contemporary military and civilian literature with operational experience to identify key unresolved capability gaps and examine austere surgical and critical care in LSCO, focusing on hemorrhage control, far-forward surgery, prolonged critical care, evacuation constraints, and ethical decision-making under sustained resource limitation. ( J Trauma Acute Care Surg . 2026;101: S168-S176. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.).