Executing balanced resuscitation in bleeding combat casualties: Good versus good enough?

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.