Damage Control Resuscitation

Jacob Stössel^a, Martin Teufel^b, Jan Ammann^a, Florent Josse^a,c

^a Department of Anesthesiology, Intensive Care, Emergency Medicine, and Pain Therapy, Bundeswehr Hospital Ulm

^b Training and Simulation Center, Medical Regiment 3 Dornstadt

^c Tactical Medicine Working Group, German Society for Military Medicine and Military Pharmacy, Bonn

Summary

Uncontrolled hemorrhage remains the most common potentially preventable cause of death in combat and occurs predominantly within the first minutes after injury. Damage control resuscitation (DCR) addresses this problem by consistently prioritizing hemorrhage control, adopting a restrictive fluid strategy, early hemostatic stabilization, and preventing hypothermia as integral components of a time-critical treatment concept. This article describes the pathophysiological foundations of hemorrhagic shock, explains the principles of DCR, and outlines practical measures relevant to tactical casualty care and treatment along the evacuation chain.

Keywords: damage control resuscitation; tactical combat casualty care; hemorrhagic shock; coagulopathy; hypothermia; military medicine; evacuation chain

Introduction and Operational Relevance

Hemorrhages continue to significantly determine early mortality in military conflicts. Various studies confirm that a substantial portion of combat-related fatalities is potentially avoidable and primarily attributed to uncontrolled bleeding [16]. This underscores the necessity for a consistent prioritization of hemorrhage control in casualty care [35]. This principle is reflected in current publications and trauma care concepts, such as the MARCH or cABCDE frameworks (cABCDE: critical bleeding, Airways, Breathing, Circulation, Disability, Exposure). The MARCH protocol is a priority-based care model for trauma patients in tactical or life-threatening situations, prioritizing massive hemorrhage (M) over airway management (A), respiration (R), circulation (C), and hypothermia/head injuries (H). The cABCDE framework is a structured approach in emergency and rescue medicine.

The implementation of aggressive initial measures should not be delayed until medical personnel are present; they must occur directly at the point of injury through self- and buddy-aid. Simultaneously, acute hemorrhage treatment should commence on the battlefield and be structured within a damage control resuscitation (DCR) package to ensure survival [33].

DCR emerged from practical experiences in military trauma care and was early on understood as an integrated treatment concept, inseparably linked with damage control surgery (DCS). While DCS aims to achieve rapid surgical control of bleeding and contamination, DCR focuses on initial physiological stabilization of severely injured patients. DCS involves not just isolated interventions, but the coordinated and standardized application of several measures, which must be situationally adapted to tactical conditions, available resources, and the possibilities for further transfer to subsequent levels of care [15]. Table 1 provides an overview of the terminologies.

Tab. 1: Classification and overview of terminologies [24]

Pathophysiological Foundations

Hemorrhagic shock is a complex systemic disorder that cannot be solely reduced to hypovolemia but is characterized by a combination of tissue hypoperfusion, metabolic acidosis, and coagulopathy. Early in its course, trauma-induced coagulopathy (TIC) can develop, exacerbated by hypoperfusion, inflammatory activation, consumption of coagulation factors, and iatrogenic dilution. Hypothermia further aggravates coagulopathy, while acidosis reduces the enzymatic activity of the coagulation cascade. This mutually reinforcing pathophysiological pattern is classically described as the lethal triad of hypothermia, acidosis, and coagulopathy and has been expanded in recent concepts to include hypocalcemia, termed the lethal diamond. Without targeted therapeutic intervention, this process frequently leads to progressive hemorrhage and a fatal outcome [14].

Principles of Damage Control Resuscitation

DCR describes a structured therapeutic concept that operates at varying levels of treatment, with different intensities and degrees of invasiveness. The goal of each measure must be to halt further blood loss, stabilize compromised coagulation, and restore tissue perfusion by replacing lost blood volume. Through these interventions, the progression of the lethal triad can be limited, thereby ensuring the fundamental prerequisites for the trauma patient’s survival.

Hemorrhage Control

In a tactical combat casualty care (TCCC) setting, the principle is: “Stop the bleeding first.” Through compression, wound packing, application of pressure dressings, and use of tourniquets, the casualty must be initially managed at the point of injury to enable survival until further treatment [7][35].

Blood pressure should not be raised to normal levels until hemorrhage control is achieved to avoid rebleeding and dilutional coagulopathy from fluid overinfusion (permissive hypotension). This approach often relies on clinical surrogates such as a palpable radial pulse or maintained consciousness, given that there is no traumatic brain injury [5]. This concept can generally be applied to trauma patients but is particularly significant in cases of non-compressible torso hemorrhages (NCTH) of the thorax and abdomen. Here, direct hemorrhage control without surgical intervention is rarely possible, so, in addition to the other measures listed, reducing blood loss through permissive hypotension until reaching the surgical treatment level, with the possibility of DCS, is an established component of shock management [1]. The target blood pressure is an arterial mean pressure of 65 mmHg or a systolic pressure of 80 mmHg; raising the blood pressure above this level should not occur. If a traumatic brain injury is present, the mean arterial pressure should be raised to 85 mmHg or the systolic pressure to>100 mmHg to ensure cerebral perfusion, even with developing intracranial pressure [17][29].

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)

For temporary control of life-threatening, non-compressible hemorrhages in severely injured patients, various invasive and non-invasive procedures are available, whose use depends on the source of bleeding, the clinical patient condition, and especially the available expertise. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is intended to rapidly reduce distal blood loss and centrally redistribute cardiac output through complete or partial occlusion of the aorta. This could improve cerebral and coronary perfusion. However, it is only a bridging measure until definitive surgical hemorrhage control is achieved and is always time-limited due to ischemic complications, particularly with occlusion in Zone 1 (thoracic position above the celiac trunk) [7][37]. Preventive placement without aortic occlusion in critical but still stable trauma patients, and balloon inflation in case of clinical deterioration, are potential applications, especially in the context of anticipated prolonged transport and treatment times to higher-level treatment facilities. Given the required expertise for cannulating the femoral artery and managing blocked and partially blocked catheters, this technique is most appropriately seen at the Role 2 level of care.

Abdominal Aortic and Junctional Tourniquet (AAJT)

An alternative, less invasive procedure is the Abdominal Aortic and Junctional Tourniquet (AAJT). Through external compression of the infrarenal or suprarenal aorta, proximal hemorrhage control can be achieved in the sense of a Zone-3-REBOA for pelvic injuries or severe lower extremity hemorrhages. Additionally, a Zone-1 effect could be achieved through a relevant increase in intra-abdominal pressure, significantly reducing blood loss from intra-abdominal injuries [31]. This allows rapid and effective temporary proximal hemorrhage control, particularly in prehospital or resource-limited settings without arterial vascular access. Additionally, otherwise difficult-to-manage junctional injuries in the groin, axillary, and neck regions can be quickly and adequately ­managed. The application is easy to train and to implement, allowing for initial proximal hemorrhage control already outside the first medical treatment facilities [5][6][9][31].

Clamshell Thoracotomy

In contrast, the resuscitative thoracotomy with aortic clamping, the clamshell thoracotomy, represents the most invasive procedure and is primarily used in traumatic cardiac arrest in penetrating thoracic injuries or imminent death. It allows immediate proximal hemorrhage control through aortic clamping, direct hemorrhage control, and treatment of a pericardial tamponade. However, this requires surgical expertise or special training to perform, as well as capacities for medical stabilization, e.g., through massive transfusion and differentiated coagulation therapy. Consequently, this measure is more appropriately located at the Role 2 Forward Surgical Element (FSE) level [23][30].

Measures for Coagulation Stabilization

Stabilizing hemostasis requires a multimodal therapeutic approach, which must begin at the point of injury and be intensified along the evacuation chain. Initially, preventing hypothermia is crucial to maintaining enzyme function in the coagulation cascade. Trauma patients quickly lose heat due to injury and blood loss, as well as environmental factors like weather exposure; hypothermia is linked to increased mortality in trauma and should be prevented whenever possible [15].

During initial injury, an increased release of plasminogen activators (t-PA) is postulated, leading to generalized hyperfibrinolysis and subsequent increased blood loss. Tranexamic acid (TXA) is an established drug for preventing and treating this hyperfibrinolysis, but it must be administered within the first two hours after injury to be effective. Additionally, another gram of TXA should be given over eight hours. The administration of TXA can significantly reduce trauma-related mortality and is a key part of guideline-based trauma treatment [4][28][29].

Fibrinogen plays a key role in the coagulation process. Early in hemorrhagic shock, fibrinogen levels drop quickly, leading to more blood loss because of poor clot formation. Giving fibrinogen early can strengthen clots and help reduce blood loss. Coagulation therapy is ideally guided by viscoelastic testing methods. However, these are usually not available in the first hours during military operations. Empirical treatment following massive transfusion protocols (see also the article on massive transfusion in this issue) should start as early as possible, but only after TXA administration, preferably at Role 2, or even better at Role 1 [17][25].

Additionally, calcium (Ca²⁺) is crucial in coagulation therapy as a cofactor for coagulation factor IV. Blood loss and transfusion of citrate-containing blood products cause hypocalcemia, which worsens coagulopathy and is linked to higher mortality. Early administration of 2 g of calcium gluconate is necessary as a part of DCR, and calcium must be given in a fixed ratio with the blood products transfused during massive transfusions [38].

Volume Replacement and Transfusion

Volume therapy in hemorrhagic shock has several objectives. It aims to restore preload reduction caused by hypovolemia, which leads to decreased cardiac output. Usually, balanced crystalloid infusion solutions are used to boost stroke volume and subsequently increase cardiac output. This helps maintain perfusion of peripheral resistance vessels and reduces cellular hypoxia. However, most infusion solutions remain only about one-third within the intravascular compartment, so their preload-increasing effect is short-lived. In DCR, the goal is to minimize crystalloid use and instead replace lost blood through transfusion [11]. Forced and uncontrolled intravenous fluid therapy for volume replacement can cause dilutional coagulopathy and is not a definitive solution. Nevertheless, it is often the only initial treatment option available, especially in remote or forward DCR settings [17]. Here, the strategy of permissive hypotension is particularly important to avoid overinfusion [13][33].

Key Point:

The purpose of volume therapy in hemorrhagic shock is to maintain proper tissue perfusion. When blood products are not available, perfusion should be temporarily sustained with balanced, acetate-buffered crystalloid infusion solutions.

For administering various infusion solutions, medications, and blood products, secure intravascular access is essential. Peripheral venous access remains the clinical standard. However, it can be difficult to establish, especially during the early stages of tactical casualty care and in patients experiencing hemorrhagic shock, particularly by less experienced personnel. Therefore, training must be intensified, and intravenous access should be established as early as possible before the casualty is moved to a centralized facility. As an alternative, intraosseous access has become a proven and effective option. It should be selected when intravenous access is not feasible. During ongoing care, central venous access routes, such as in Role 2, can be established to ensure therapy aligns with clinical standards. Other methods, like subcutaneous fluid administration (hypodermoclysis), are not internationally standardized, do not provide adequate volume therapy for severely injured patients, and should be avoided. However, within prolonged field care, both oral and rectal administration are safe, more effective, and practically feasible [8].

Whole Blood

For patients with severe hemorrhagic shock, early blood transfusion is a vital part of DCR. The goal is to restore oxygen delivery, hemostasis, and circulating blood volume simultaneously. Transfusing red blood cell concentrates (RBCs) mainly enhances oxygen transport but does not fix trauma-induced coagulopathy and may worsen it through dilution. Plasma products supply crucial coagulation factors and support endothelial health, while platelets are essential for primary hemostasis and clot stabilization.

The combined administration of these blood components in a fixed ratio of RBCs to plasma to platelets (4:4:1) aims to effectively replace the functional properties of lost whole blood [20][32].

In this context, whole blood transfusion is a physiological concept, as it contains red blood cells, plasma, and platelets in native composition, fulfilling both oxygenating and hemostatic functions simultaneously. Especially, low-titer group O whole blood allows rapid, practical transfusion in bleeding trauma patients compared with component therapy and is associated with favorable hemostatic effects and improved survival [6][34].

In Germany, whole blood is currently applicable only in exceptional and extreme situations, so bleeding therapy continues to be based on blood component transfusion. To mimic the functional properties of whole blood as closely as possible, red blood cell concentrates, plasma, and platelets are administered in fixed ratios according to transfusion protocols.

Plasma Products

Historically, plasma products were not used as part of prehospital bleeding treatment because of the need for cold chain storage and a time-consuming thawing process. With the development of freeze-dried plasma products, such as LyoPlasma available in Germany since 2007, rapid and even prehospital plasma administration has become possible. No cooling or thawing is necessary; reconstitution can be done within minutes directly at the patient. LyoPlasma is used in Germany and, for example, in Australia, the United Kingdom, France, and Israel in civilian and military emergency medicine [21][2].

Early plasma administration is a vital part of modern care for bleeding patients, targeting key mechanisms of hemorrhagic shock. Especially in the initial phase after trauma, there is a quick loss of coagulation factors and the development of trauma-induced coagulopathy, which can be worsened by forced crystalloid-based volume therapy. Prehospital plasma helps replace essential coagulation proteins early on and is linked to lower early and 30-day mortality, especially when given quickly after injury (within the first six hours) and near the incident site [9][19].

The application of plasma in the prehospital setting is safe, practical, and has a favorable benefit-to-risk profile. Today, it is an integral part of DCR [2]. Modern plasma formulations, including lyophilized preparations, maintain coagulation function and offer additional logistical advantages, making them a relevant option in stabilizing acutely bleeding patients, especially within tactical medicine [22][34]. Here, early use by non-medical personnel should be considered (Figure 1).

Fig. 1: French special forces treating a wounded soldier with blood and Lyoplasma. (Photo of a French soldier, publication consent obtained from the authors)

Colloidal Infusion Solutions

The significance of hydroxyethyl starch (HES)-containing infusion solutions has been greatly limited in Germany in recent years due to multiple studies, warnings from the Food and Drug Administration (FDA, USA), and a Red Hand Letter, published by the Paul-Ehrlich-Institute, Berlin. The current revised guideline on intravascular volume therapy mentions HES- and gelatin-containing infusion solutions as options for treatment after active blood loss [12]. The European guideline is more restrictive and highlights that artificial colloidal volume replacement agents should be considered very cautiously, as they do not clearly outperform crystalloid infusion solutions and may have negative effects on coagulation [32]. According to the Committee on Tactical Combat Casualty Care (CoTCCC), so-called volume expanders are not standard medications for treating hemorrhagic shock [7][9][11]. It’s important to note that artificial “colloids” cannot replace blood transfusions for stabilization but can help conserve crystalloid infusion solutions in severely resource-limited situations. They rapidly and effectively stabilize circulation and serve as a bridge until blood products become available or can be supplied again. Furthermore, the logistics and use, especially of gelatin-containing infusion solutions, are straightforward and do not require additional training like HES [26].

Table 2 shows shows the implementation of various Damage Control Resuscitation measures along the casualty’s evacuation chain [8][18][36].

Tab. 2: Current training situation, authors’ recommendations for measures within DCR for different training levels compared to US counterparts
Legend: - not trained; + trained & recommended/meaningful, (+) not trained, but meaningful/recommended; EH-B – First Responder Bravo, -MedPer – Medical Personnel, EinsSan – Deployment Paramedic, NotSan – Emergency Paramedic, RettMed – Emergency Physician

Lessons Learned from Current Conflicts

Israel/Gaza

Experiences gained on the Israeli side during the Gaza conflict significantly contribute to the further development of individual DCR elements and lead to a more precise practical implementation, especially in prehospital and tactically constrained environments. A central finding is the consistent prioritization of the earliest possible hemorrhage control through simple, robust, and widely teachable measures. As in previous conflicts, it is again evident that avoidable fatalities are predominantly due to uncontrolled hemorrhages. The systematic introduction of standardized tourniquets and hemostatic wound packing, combined with structured training of even non-medical personnel, measurably improves care quality. Simultaneously, there is a relevant rate of incorrect applications, underscoring the need for regular training cycles and standardized algorithms.

The early administration of tranexamic acid in suspected severe hemorrhage is consistently used, often with a liberal indication, given its favorable benefit-to-risk profile. Concurrently, the shift from crystalloid solutions to plasma- and whole blood-based volume therapy has been confirmed. The use of freeze-dried plasma and low-titer whole blood proved clinically effective but requires stable cold chains, standardized processes, and trained personnel [34][35].

Ukraine

While this is possible in the Gaza conflict due to short transport times and a dense hospital network, experiences from Ukraine highlight the limits of this approach under conditions of large-scale conventional battles (Large Scale Combat Operations, LSCO). There, evacuation times of several hours to a day or more are common, so Prolonged Field Care must be routinely performed [27].

The traditional evacuation process with rapid transport to higher levels of care is only partially feasible under constant drone threats and targeted attacks on medical infrastructure. Evacuations often face delays during twilight or nighttime, requiring the creation of casualty collection points with enhanced capabilities. These include blood products, oxygen, telemedicine, and the ability for temporary intensive monitoring. DCR must necessarily start at the point of injury and requires an expansion of medical skills to lower levels of care. Non-medical personnel must be trained to administer blood products, secure airways, and provide long-term shock management. Competency-based training and train-the-trainer methods are essential resilience factors.

Another practical learning area involves structured medical mission planning. Rigid role concepts prove inadequate under LSCO conditions. Simultaneously, it becomes clear that missing or fragmented documentation hinders systematic learning. Digital recording and standardized data systems are essential for evaluating treatment outcomes and continuously adjusting treatment algorithms. Figure 2 shows a possible algorithm developed by the authors.

Fig. 2: Rationale of a possible treatment algorithm for hemorrhagic shock (own illustration).

Finally, experiences from Ukraine indicate that prolonged shock, massive transfusions, and combined thoracic or traumatic brain injuries are associated with an increased rate of persistent multi-organ failure. Long evacuation times significantly worsen the prognosis and require early, consistent shock therapy, including coagulation management, calcium substitution, and heat retention already in the field.

Conclusion

In summary, the current conflicts demonstrate that damage control resuscitation under modern combat conditions must be applied consistently, in a decentralized manner, based on competency, and supported by strong logistics. Key elements include early hemorrhage control, rapid coagulation stabilization, strategies employing whole blood or plasma, structured heat management, expanded capabilities at lower levels of care, and adaptive planning and documentation systems. The success of DCR depends less on ideal conditions and more on comprehensive training, standardization, and the ability to continually adapt to a dynamic operational environment [3].

References

1. Adams D, McDonald PL, Sullo E, et al. Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere/remote environments: protocol for a scoping review. Trauma Surg Acute Care Open. 2021 Oct 19;6(1):e000811. mehr lesen
2. Ateek J, MacDonald S, Goldstein J, et al. State of the Evidence for Prehospital Plasma Infusion for Patients with Suspected Traumatic Hemorrhage: A Rapid Review by the Prehospital Evidence-Based Practice Program. Air Med J 2025;44:242–255. mehr lesen
3. Beck K, Lennartz S, Fritsch J, Josse F. Combat Medical Care Conference July 2–3, 2025: Summary of Main Track Lectures. WMM 2025; 69(10-11E): 4. mehr lesen
4. Boudreau RM, Deshpande KK, Day GM, et al. Prehospital Tranexamic Acid Administration During Aeromedical Transport After Injury. J Surg Res. 2019 Jan;233:132-138. mehr lesen
5. Brännström A, Rocksén D, Hartman J, et al. Abdominal Aortic and Junctional Tourniquet release after 240 minutes is survivable and associated with small intestine and liver ischemia after porcine class II hemorrhage. J Trauma Acute Care Surg. 2018 Oct;85(4):717-724. mehr lesen
6. Cap A, Gurney J, Spinella PC, et al. Joint Trauma System Clinical Practice Guide: Damage Control Resuscitation Internet]. 2019.[last access January 11, 2026]: available from: https://jts.health.mil/assets/docs/cpgs/Damage_Control_Resuscitation_12_Jul_2019_ID18.pdf mehr lesen
7. Charbit J, Dagod G, Darcourt S, et al. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in a multidisciplinary approach for management of traumatic haemorrhagic shock: 10-year retrospective experience from a French level 1 trauma centre. Injury. 2025 Jan;56(1):111952. mehr lesen
8. Committee on Tactical Combat Casualty Care (CoTCCC). Tactical Combat Casualty Care (TCCC) Guidelines [Internet]. 2024. [last access January 26, 2026]; available from: https://trema-europe.de/wp-content/uploads/2025/07/TCCC-Guidelines-25-Jan-2024-1.pdf mehr lesen
9. Committee on Tactical Combat Casualty Care (CoTCCC). Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel 2021 [Internet]. 2021.[last access January 23, 2026]; available from: https://learning-media.allogy.com/api/v1/pdf/1045f287-baa4-4990-8951-de517a262ee2/contents mehr lesen
10. Davenport R, Curry N, Fox EE, et al. CRYOSTAT-2 Principal Investigators. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1882-1891. mehr lesen
11. Deaton TG, Auten JD, Betzold R, et al. Fluid Resuscitation in Tactical Combat Casualty Care; TCCC Guidelines Change 21-01. 4 November 2021. J Spec Oper Med. 2021 Winter;21(4):126-137. mehr lesen
12. Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen. AWMF-Reg.-Nr.: 001-020. 2020. mehr lesen
13. Dhillon NK, Kwon J, Coimbra R. Fluid resuscitation in trauma: What you need to know. J Trauma Acute Care Surg. 2025 Jan 1;98(1):20-29. mehr lesen
14. Ditzel RM Jr, Anderson JL, Eisenhart WJ, Rankin CJ, DeFeo DR, Oak S, Siegler J. A review of transfusion- and trauma-induced hypocalcemia: Is it time to change the lethal triad to the lethal diamond? J Trauma Acute Care Surg. 2020 Mar;88(3):434-439. mehr lesen
15. Duchesne JC, Pereira BM, Fraga GP. Damage Control Resuscitation. Trauma Surgery. 2013 Aug 19:27–42. mehr lesen
16. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001-2011): implications for the future of combat casualty care. J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S431-S4377. mehr lesen
17. Hussmann B, Hilbert-Carius P, Berk T, et al. Prehospital coagulation management and fluid replacement therapy in patients with multiple and/or severe injuries - A systematic review and clinical practice guideline update. Eur J Trauma Emerg Surg. 2025 Nov 14;51(1):328. mehr lesen
18. Josse F. Tactical Medicine and Tactical Casualty Care: History, Development, Principles, and Areas of Application. WMM (2025); 69(6E): 2. mehr lesen
19. Lewis RE, Muluk SL, Reitz KM, et al. Prehospital plasma is associated with survival principally in patients transferred from the scene of injury: A secondary analysis of the PAMPer trial. Surgery. 2022 Oct;172(4):1278-1284. mehr lesen
20. Lier H. Massivtransfusion - ein Update [Internet]. hämotherapie 2023.[last access14. Februar 2026]; available from: https://www.drk-haemotherapie.de/beitraege/massivtransfusion-ein-update mehr lesen
21. NSW Agency for Clinical Innovation. Freeze-dried plasma administration in trauma – Review of literature and key findings [Internet]. Sydney ACI 2023. [last access March 12, 2026]; available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/836521/ACI-Freeze-dried-plasma-administration-in-trauma-evidence-report.pdf mehr lesen
22. Peng HT, Singh K, Rind SG, daLuz L, Beckett A. Dried Plasma for Major Trauma: Past, Present, and Future. Life 2024;14(5):619. mehr lesen
23. Perkins ZB, Greenhalgh R, Ter Avest E, et al. Prehospital Resuscitative Thoracotomy for Traumatic Cardiac Arrest. JAMA Surg. 2025 Feb 26;160(4):432–40. mehr lesen
24. Peschman JR, Glassberg E, Jenkins D. Remote Damage Control Resuscitation. In: Spinella PC. Damage Control Resuscitation. Cham: Springer International Publishing, 2020. S. 85–100. mehr lesen
25. Pretty S, O'Dochartaigh D, Cross E, et al. Prehospital Fibrinogen Levels in Major Trauma Patients Transported by Helicopter Emergency Medical Service: Determining Who Might Benefit. J Spec Oper Med. 2025 Dec 1;25(4):26-32. mehr lesen
26. Querschnitts-Leitlinien zur Therapie mit Blutkomponenten und Plasmaderivaten [Internet]. Bundesärztekammer 2020.[last access March 2025]; available from: https://www.bundesaerztekammer.de/fileadmin/user_upload/_old-files/downloads/pdf-Ordner/MuE/Querschnitts-Leitlinien_BAEK_zur_Therapie_mit_Blutkomponenten_und_Plasmaderivaten-Gesamtnovelle_2020.pdf mehr lesen
27. Quinn J, Onderková A, Holmstrøm E, et al. Damage Control Resuscitation Ukraine: Small Unit Training in Large Scale Combat Operations, Lessons Learned/Shared and Future Directions. Mil Med. 2025 Sep 1;190(Supplement_2):431-436. mehr lesen
28. Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar;17(10):1-79 mehr lesen
29. S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung (Register-Nr. 187-023) [Internet].AWMF 2022.[last access March 15,2026]; available from: https://register.awmf.org/assets/guidelines/187-023l_S3_Polytrauma-Schwerverletzten-Behandlung_2023-06.pdf. mehr lesen
30. Shaw J, Brenner M. Resuscitative Endovascular Balloon Occlusion of the Aorta: What You Need to Know. J Trauma Acute Care Surg. 2025 Jun 1;98(6):831-839. mehr lesen
31. Smith T, Pallister I, Parker PJ. Abdominal Aortic Junctional Tourniquets: Clinically Important Increases in Pressure in Aortic Zone 1 and Zone 3 in a Cadaveric Study Directly Relevant to Combat Medics Treating Non-Compressible Torso Hemorrhage. J Spec Oper Med. 2025 Apr 30;24(4):17-22. mehr lesen
32. Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98. mehr lesen
33. Spinella PC. Damage Control Resuscitation. Cham: Springer International Publishing, 2020. mehr lesen
34. Talmy T, Mitchnik IY, Malkin M, et al. Adopting a culture of remote damage control resuscitation in the military: Insights from the Israel defense forces decade of experience. Transfusion. 2023 May;63 Suppl 3:S83-S95. mehr lesen
35. Talmy T, Malkin M, Esterson Aet al. Low-titer group O whole blood in military ground ambulances: Lessons from the Israel Defense Forces initial experience. Transfus Med. 2023 Dec;33(6):440-452. mehr lesen
36. TREMA e.V. Leitlinien der TREMA e.v. für Taktische Verwundetenversorung (Tactical Combat Casualty Care) - Version 3.1. 2025 [Internet].TREMA 2025.[last access January 20, 2026];available from: https://trema-europe.de/wp-content/uploads/2025/06/TREMA-e.V.-Guidelines-fuer-TCCC-3.1_final.pdf mehr lesen
37. van de Voort JC, Kessel B, Borger van der Burg BLS, DuBose JJ, Hörer TM, Hoencamp R. Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study. J Trauma Acute Care Surg. 2024 Jun 1;96(6):921-930. mehr lesen
38. Weber S, Beres J, Hossfeld B, Kulla M. Kalzium in der Notfallmedizin — Update 2024. Notfallmedizin up2date 2024:19(02): 233–249. mehr lesen

Manuscript Data

Citation

Stössel J, Teufel M, Ammann J, Josse F. Damage Control Resuscitation. WMM 2026;70(5E):4.

DOI: https://doi.org/10.48701/opus4-880

For the Authors

Major (MC) Dr. Jacob Stössel

Department for Anesthesiology, Intensive Care, Emergency Medicin and Pain Therapy

Bundeswehr Hospital Ulm

Oberer Eselsberg 40, D-89081 Ulm

E-Mail: jacobstoessel@bundeswehr.org