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

BACKGROUND: Data-driven best practices recommend balanced resuscitation in a 1:1:1 (RBC:FFP:PLT) ratio - supported by a randomized trial demonstrating a reduction in mortality from exsanguination. Although adoption of this is widely advertised, recent civilian literature has shown that adherence is poor. We sought to evaluate the adherence to balanced resuscitation in the first 6 hours among combat casualties injured in Iraq and Afghanistan. METHODS: A retrospective analysis was performed using the Deployed Hemostatic Emergency Resuscitation of Traumatic Exsanguinating Shock data set. Injured combat casualties, with available transfusion timing data, treated at US military medical treatment facilities in Afghanistan and Iraq between 2002 and 2022, were included. Patients who received any whole blood (WB) were compared with those who received only component therapy (CT). Primary outcomes were calculated as RBC:FFP and RBC:PLT ratios, at 15-minute intervals from the time of injury through 6 hours. RESULTS: In all, 4,500 casualties met the inclusion criteria, with 793 receiving WB and 3,707 receiving only CT. The median age was 25 (21, 30), 96% were male, with a mortality rate of 13.5%. Among these, 66% sustained blast/explosion mechanism, with a median injury severity score of 18 (12, 29). By 6 hours, 52% versus 48% and 80% versus 69% of WB versus CT patients had achieved a 1:1 and 1.5:1 RBC:FFP ratio, respectively. Median RBC:PLT ratios showed greater variability, ranging from 1:1 to 2:1 in WB patients and 2:1 to 4:1 in CT patients. At all time points, WB patients achieved better ratios for both plasma and platelets. CONCLUSIONS: Approximately 50% of US combat casualties are resuscitated in a balanced fashion, far greater than that observed in recent civilian data. However, a higher proportion of patients with an early use of WB achieved 1:1:1. Wider availability of WB and increasing inventory of platelets and plasma products should be explored to improve battlefield resuscitation. ( J Trauma Acute Care Surg. 2026;101: S114-S121. Copyright © 2026 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.). LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.