The Use of Hemostatic Agents in Traumatic Bleeding: One Size Does Not Fit All

Hemostatic agents (bleeding-stopping agents) are pharmacological or biological substances used to induce hemostasis in cases of trauma, surgical interventions, or spontaneous bleeding. These agents act at various steps of primary and secondary hemostasis, promoting clot formation, reducing blood loss, and improving patient outcomes. This narrative review examines the current status of hemostatic agents and highlights major developments and gaps in the field.

A systematic literature search was used to identify relevant articles. Consecutive trials in English between 2005 and 2025 investigating the indications and use of hemostatic agents were abstracted with a search in Google Scholar, PubMed, Scopus, Web of Science, and MEDLINE registries. Case reports, editorials, and expert opinions were excluded from the analysis.

The use of tranexamic acid has recently been reintroduced, especially in trauma patients. It should be used in exsanguinating victims of trauma and resultant hemorrhagic shock. Prothrombin Complex Concentrates (PCC) have emerged as a favorable choice over Fresh Frozen Plasma (FFP) in bleeding due to vitamin K antagonists and other anticoagulants, and their use is increasing with studies. On the other hand, FFP is recommended when alternative treatment options are unavailable or in conjunction with first-choice agents, in narrowed indications due to possible complications.

The evidence underscores that no single hemostatic agent is universally superior; optimal management requires individualized selection based on the mechanism of bleeding, underlying coagulopathy, and patient-specific factors. TXA has demonstrated consistent survival benefits in traumatic hemorrhage when administered early, yet its efficacy diminishes beyond the 3-hour window, emphasizing time-sensitivity in clinical decision-making. PCC offers practical advantages over FFP in anticoagulant reversal, including faster INR normalization, lower volume load, and no compatibility requirements, but its role in massive transfusion remains limited by the absence of factor V. FFP retains utility as an adjunct in complex coagulopathies and resource-limited settings. The integration of point-of-care viscoelastic testing (TEG/ROTEM) represents a significant advancement in guiding goal-directed hemostatic therapy and reducing unnecessary transfusions. Emerging agents and antidotes for DOAC reversal further expand the therapeutic landscape, though cost and availability remain barriers.

Treatment with hemostatic agents can be lifesaving, especially after being adjusted for individual risks and benefits. Therefore, the selection of agents should be tailored on a case-by-case basis.