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Updated: Jun 13, 2026

Integrated Compensatory Responses in a Human Model of Hemorrhage
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Executing balanced resuscitation in bleeding combat casualties: Good versus good enough?

Jan-Michael Van Gent1, Amanda M Staudt, Jennifer M Gurney

  • 1Joint Trauma System (J-M.V.G., J.M.G.), Defense Health Agency, Joint Base San Antonio-Fort Sam Houston, Texas; Department of Surgery at The McGovern Medical School at the University of Texas Health Science Center (J-M.V.G., B.A.C.), Houston, Texas; The Geneva Foundation (A.M.S.), DHA, JBSA Fort Sam Houston, Houston, Texas.

The Journal of Trauma and Acute Care Surgery
|June 12, 2026
PubMed
Summary

Approximately 50% of combat casualties receive balanced resuscitation, a rate higher than in civilian trauma care. Early use of whole blood (WB) improved adherence to the 1:1:1 ratio for red blood cells (RBCs), fresh frozen plasma (FFP), and platelets (PLT).

Keywords:
Traumabalanced resuscitationcombat casualtieswhole blood

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Area of Science:

  • Trauma resuscitation
  • Hemorrhagic shock management
  • Military medicine

Background:

  • Balanced resuscitation (1:1:1 RBC:FFP:PLT ratio) is recommended to reduce exsanguination mortality.
  • Adherence to balanced resuscitation protocols is reportedly poor in civilian trauma care.
  • This study evaluates adherence to balanced resuscitation in combat casualties.

Purpose of the Study:

  • To assess adherence to balanced resuscitation (1:1:1 RBC:FFP:PLT ratio) within the first 6 hours post-injury in combat casualties.
  • To compare resuscitation ratios between patients receiving whole blood (WB) and component therapy (CT).

Main Methods:

  • Retrospective analysis of the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock data set.
  • Inclusion of combat casualties treated at US military facilities in Afghanistan and Iraq (2002-2022) with transfusion timing data.
  • Comparison of RBC:FFP and RBC:PLT ratios at 15-minute intervals up to 6 hours between WB and CT groups.

Main Results:

  • 4,500 casualties included; 793 received WB, 3,707 received CT. Overall mortality was 13.5%.
  • By 6 hours, 52% of WB patients achieved a 1:1 RBC:FFP ratio vs. 48% of CT patients.
  • WB patients consistently achieved better RBC:FFP and RBC:PLT ratios compared to CT patients throughout the study period.

Conclusions:

  • Approximately 50% of US combat casualties received balanced resuscitation, exceeding rates seen in civilian data.
  • Early administration of whole blood (WB) was associated with a higher proportion of patients achieving the 1:1:1 resuscitation ratio.
  • Increased availability of WB and optimized inventory of plasma and platelets are recommended for improved battlefield resuscitation.