Advancements in Prehospital, En-Route, and Damage Control Casualty Care and Areas of Future Research for Large-Scale Combat Operations
Authors: Remondelli Mason H. , Rhee Joseph , Barzanji Natalia K. , Wang Jonathan , Green John T. , Do Woo , Bozzay Joseph D. , Walker Patrick F. , Bradley Matthew J. 
Published: February 2025

Abstract

Purpose of Review
The purpose of this review is to describe the advancements in combat casualty care from the prehospital environment, through en route care, and into damage control resuscitative and surgical care during recent military conflict. We also explore potential areas of future research needed to enhance survivability on the future battlefield during large-scale combat operations (LSCO).

Recent Findings
In the prehospital space, the use of tourniquets has become standard practice for controlling severe hemorrhage, while techniques like Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) continue to be researched for managing hemorrhagic shock. Implementing whole blood transfusions and freeze-dried plasma enables hemostatic resuscitation. Pain management strategies are also evolving, with the use of ketamine, Penthrox, and fentanyl. During en route care, the concept of the “golden hour” emphasizes the urgency of delivering timely medical intervention, and critical care paramedics play an essential role in this setting. En route resuscitation and surgical teams enable rapid, lifesaving interventions during patient transport. Within damage control resuscitation and surgery, the focus has shifted towards hemostatic resuscitation with blood products to counteract coagulopathy and prevent further bleeding. Damage control laparotomy remains a critical intervention for severe abdominal injuries, while vascular shunting techniques are being utilized extensively to stabilize patients with limb-threatening injuries. Likewise, acellular vessel conduits are a novel, promising innovation, offering a bioengineered solution for vascular repair. For future LSCO, novel combat casualty care research must delve into anti-shock drugs aimed at enhancing hemodynamic stability, the use of Extracorporeal Membrane Oxygenation for severe combat trauma, and the development of novel antimicrobials to combat post-traumatic infections. Directed energy technologies, telemedicine, decision-assist tools, and autonomous systems are also being investigated, with the potential to transform trauma care by improving response times and treatment efficacy in remote or resource-limited environments.

Summary
Recent combat casualty care advancements, such as hemorrhage control methods like tourniquets and REBOA, alongside innovations in resuscitation techniques like whole blood transfusions and freeze-dried plasma, exemplify improving prehospital and en route care. The golden hour policy, en route resuscitation, and improvement in surgical capabilities highlight the importance of timely interventions in saving lives. Novel research areas, including anti-shock drugs, ECMO, antimicrobials, directed energy technologies, telemedicine, decision-assist tools, and autonomous systems, could enhance survivability in future large-scale combat operations.