Bandages have been used in hemorrhage control since at least ancient Egyptian, Greek, and Roman times. The design remained unchanged until the fifth century BCE, when gauze was introduced. Modern bandages are relatively expensive and heavy and are not widely available in low-resource environments. Packaging wrap, sometimes called Saran wrap, cling film, cling wrap, or Glad wrap, is widely available in many countries. It is used commercially with handheld dispensers to bind goods to pallets for secure transport. In austere settings, packaging wrap has a large number of improvised medical uses. It can be used as a dressing to apply pressure to wounds, as covering for burns, to splint limb fractures, to occlude bowel evisceration, and to ensure the security of casualty cards. It can also be used to create an endotracheal tube tie, an improvised intravenous fluid pressure infuser, an improvised pneumatic limb tourniquet, or a head immobilizer for spinal immobilization. Large numbers of dressings can be created from a single dispenser, making this a cheap and light alternative to conventional dressings. Packaging wrap is not intended as a replacement for commercially available, approved products but rather to assist in packaging and for use in austere, remote and tactical environments, where space and weight are limited.

Pneumothorax resulting from injury is a common phenomenon in both civilian and military trauma. A pneumothorax or simple pneumothorax is defined as air in the pleural space. A tension pneumothorax can evolve from a simple pneumothorax if there is a continued air leak from the lung without mechanism for egress. This occurs due to an expanding air volume and pressure in the pleural space. The tension pneumothorax results in obstructive shock that may be a life-threatening emergency. All types of pneumothorax can occur in patients who are non-positive pressure ventilated as well as those receiving positive pressure ventilation. Positive pressure ventilation changes the dynamics of pneumothoraces in that it can exacerbate an air leak, resulting in a simple pneumothorax evolving into a tension pneumothorax. The pathophysiology and clinical presentation of these traumatic conditions represent two differing sub-pathologies, and, although they share the same underlying physiological process in the opinion of the authors, a different approach should be adopted when considering treatment. The objective of this manuscript is to discuss the etiology, incidence, and clinical significance of simple and tension pneumothoraces. This paper will propose a uniform description of pathophysiology and diagnostic elements as well as treatment strategies. The intent is to provide a standardization of the nomenclature as well as an understanding of the physiology and clinical significance of the spectrum of pneumothoraces. Finally, we conclude with the author groups 16-point position statement on traumatic tension pneumothorax, its definition and management. The main author position is: - In spontaneously breathing pneumothorax, because of the risk of harm, suspected low incidence, high rate of misdiagnosis, and low rate of procedural success, a conservative approach is advised. - In positive pressure ventilated tension pneumothorax, the incidence is greater and the time to severe physiological impact shorter; thus a more aggressive approach is advised.

BACKGROUND:Whole blood (WB) collections can occur downrange for immediate administration. An important aspect of these collections is determining when the unit is sufficiently full. This project tested a novel method for determining when a field collection is complete. METHODS:The amount of empty space at the top of WB units, destined to become LTOWB or separated into components, that were collected at blood centers or hospitals was measured by holding a WB unit off the ground and placing the top of a piece of string where the donor tubing entered the bag. The string was marked where it intersected the top of the column of blood in the bag and measured from the top. The WB units were also weighed. RESULTS:A total of 15 different bags, two of which were measured in two different filling volumes, from 15 hospitals or blood centers were measured and weighed. The most commonly used blood bag, Terumo Imuflex SP, had a median string length of 9 mm (range: 2-24 mm) and weighed a median of 565.1 g (range: 524.8-636.7 g). CONCLUSION:Pieces of string can be precut to the appropriate length depending on the type of bag before a mission where field WB collections might be required and a mark placed on the bag before the collection commences to indicate when the unit is full.

INTRODUCTION:Tension pneumothorax (TPX) is the third most common cause of preventable death in trauma. Needle decompression at the fifth intercostal space at anterior axillary line (5th ICS AAL) is recommended by Tactical Combat Casualty Care (TCCC) with an 83-mm needle catheter unit (NCU). We sought to determine the risk of cardiac injury at this site.METHODS:Institutional data sets from two trauma centers were queried for 200 patients with CT chest. Inclusion criteria include body mass index of =30 and age 18-40 years. Measurements were taken at 2nd ICS mid clavicular line (MCL), 5th ICS AAL and distance from the skin to pericardium at 5th ICS AAL. Groups were compared using Mann-Whitney U and chi-squared tests.RESULTS:The median age was 27 years with median BMI of 23.8 kg/m2. The cohort was 69.5% male. Mean chest wall thickness at 2nd ICS MCL was 38-mm (interquartile range (IQR) 32-45). At 5th ICS AAL, the median chest wall thickness was 30-mm (IQR 21-40) and the distance from skin to pericardium was 66-mm (IQR 54-79).CONCLUSION:The distance from skin to pericardium for 75% of patients falls within the length of the recommended needle catheter unit (83-mm). The current TCCC recommendation to "hub" the 83mm needle catheter unit has potential risk of cardiac injury.

Background: Shock index (SI) equals the ratio of heart rate (HR) to systolic blood pressure (SBP) with clinical evidence that it is more sensitive for trauma patient status assessment and prediction of outcome compared to either HR or SBP alone. We used lower body negative pressure (LBNP) as a human model of central hypovolemia and compensatory reserve measurement (CRM) validated for accurate tracking of reduced central blood volume to test the hypotheses that SI: 1) presents a late signal of central blood volume status; 2) displays poor sensitivity and specificity for predicting the onset of hemodynamic decompensation; and 3) cannot identify individuals at greatest risk for the onset of circulatory shock. Methods: We measured HR, SBP and CRM in 172 human subjects (19 to 55 years) during progressive LBNP designed to determine tolerance to central hypovolemia as a model of hemorrhage. Subjects were subsequently divided into those with high (HT; n = 118) and low (LT; n = 54) tolerance based on completion of 60 mmHg LBNP. The time course relationship between SI and CRM was determined and Receiver Operating Characteristic (ROC) Area Under the Curve (AUC) was calculated for sensitivity and specificity of CRM and SI to predict hemodynamic decompensation using clinically defined thresholds of 40% for CRM and 0.9 for SI. Results: The time and level of LBNP required to reach a SI = 0.9 (~60 mmHg LBNP) was significantly greater (P < 0.001) compared to CRM that reached 40% at ~40 mmHg LBNP. SI did not differ between HT and LT subjects at 45 mmHg LBNP levels. ROCAUC for CRM was 0.95 (95%CI = 0.94-0.97) compared to 0.91 (0.89-0.94) for SI (P = 0.0002). Conclusions: Despite high sensitivity and specificity, SI delays time to detect reductions in central blood volume with failure to distinguish individuals with varying tolerances to central hypovolemia. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

BACKGROUND Shock index (SI) equals the ratio of heart rate (HR) to systolic blood pressure (SBP) with clinical evidence that it is more sensitive for trauma patient status assessment and prediction of outcome compared with either HR or SBP alone. We used lower body negative pressure (LBNP) as a human model of central hypovolemia and compensatory reserve measurement (CRM) validated for accurate tracking of reduced central blood volume to test the hypotheses that SI: (1) presents a late signal of central blood volume status; (2) displays poor sensitivity and specificity for predicting the onset of hemodynamic decompensation; and (3) cannot identify individuals at greatest risk for the onset of circulatory shock. METHODS We measured HR, SBP, and CRM in 172 human subjects (19–55 years) during progressive LBNP designed to determine tolerance to central hypovolemia as a model of hemorrhage. Subjects were subsequently divided into those with high tolerance (HT) (n = 118) and low tolerance (LT) (n = 54) based on completion of 60 mm Hg LBNP. The time course relationship between SI and CRM was determined and receiver operating characteristic (ROC) area under the curve (AUC) was calculated for sensitivity and specificity of CRM and SI to predict hemodynamic decompensation using clinically defined thresholds of 40% for CRM and 0.9 for SI. RESULTS The time and level of LBNP required to reach a SI = 0.9 (~60 mm Hg LBNP) was significantly greater (p < 0.001) compared with CRM that reached 40% at ~40 mm Hg LBNP. Shock index did not differ between HT and LT subjects at 45 mm Hg LBNP levels. ROC AUC for CRM was 0.95 (95% CI = 0.94–0.97) compared with 0.91 (0.89–0.94) for SI (p = 0.0002). CONCLUSION Despite high sensitivity and specificity, SI delays time to detect reductions in central blood volume with failure to distinguish individuals with varying tolerances to central hypovolemia. LEVEL OF EVIDENCE Diagnostic Test or Criteria; Level III.

Limb and junctional hemorrhage are leading causes of potentially preventable death among trauma casualties. Hemorrhage control for these regions could be achieved by direct or indirect pressure. The manual pressure points (MPP) involves applying manual pressure on the arterial supply to occlude distal blood flow without the need for specialized equipment.

TransfusionEarly View COMMENTARY Toward a more complete understanding of who will benefit from prehospital transfusion Mark H. Yazer, Corresponding Author Mark H. Yazer myazer@itxm.org orcid.org/0000-0001-6740-2758 Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Correspondence Mark H. Yazer, Vitalant, 3636 Blvd of the Allies, Pittsburgh, PA 15213, USA. Email: myazer@itxm.orgSearch for more papers by this authorAndrew P. Cap, Andrew P. Cap U.S. Army Institute of Surgical Research, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USASearch for more papers by this authorElon Glassberg, Elon Glassberg Israeli Defense Forces, Medical Corps, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel, The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USASearch for more papers by this authorLaura Green, Laura Green Barts Health NHS Trust, London, UK Blizard Institute, Queen Mary, University of London, London, UK NHS Blood and Transplant, London, UKSearch for more papers by this authorJohn B. Holcomb, John B. Holcomb Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, USASearch for more papers by this authorMansoor A. Khan, Mansoor A. Khan Department of Abdominal Surgery and Medicine, University Hospitals Sussex, Sussex, UKSearch for more papers by this authorErnest E. Moore, Ernest E. Moore Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USASearch for more papers by this authorMatthew D. Neal, Matthew D. Neal Pittsburgh Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorGavin D. Perkins, Gavin D. Perkins Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heartlands Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorJason L. Sperry, Jason L. Sperry Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorPatrick Thompson, Patrick Thompson Atem Ltd., Andover, UKSearch for more papers by this authorDarrell J. Triulzi, Darrell J. Triulzi Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorPhilip C. Spinella, Philip C. Spinella orcid.org/0000-0003-1721-0541 Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this author Mark H. Yazer, Corresponding Author Mark H. Yazer myazer@itxm.org orcid.org/0000-0001-6740-2758 Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA Correspondence Mark H. Yazer, Vitalant, 3636 Blvd of the Allies, Pittsburgh, PA 15213, USA. Email: myazer@itxm.orgSearch for more papers by this authorAndrew P. Cap, Andrew P. Cap U.S. Army Institute of Surgical Research, Department of Medicine, Uniformed Services University, Bethesda, Maryland, USASearch for more papers by this authorElon Glassberg, Elon Glassberg Israeli Defense Forces, Medical Corps, Israel; Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel, The Uniformed Services University of the Health Sciences, Bethesda, Maryland, USASearch for more papers by this authorLaura Green, Laura Green Barts Health NHS Trust, London, UK Blizard Institute, Queen Mary, University of London, London, UK NHS Blood and Transplant, London, UKSearch for more papers by this authorJohn B. Holcomb, John B. Holcomb Center for Injury Science, Department of Surgery, University of Alabama at Birmingham, Birmingham, USASearch for more papers by this authorMansoor A. Khan, Mansoor A. Khan Department of Abdominal Surgery and Medicine, University Hospitals Sussex, Sussex, UKSearch for more papers by this authorErnest E. Moore, Ernest E. Moore Department of Surgery, Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado, USASearch for more papers by this authorMatthew D. Neal, Matthew D. Neal Pittsburgh Trauma and Transfusion Medicine Research Center, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorGavin D. Perkins, Gavin D. Perkins Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; Critical Care Unit, Heartlands Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UKSearch for more papers by this authorJason L. Sperry, Jason L. Sperry Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorPatrick Thompson, Patrick Thompson Atem Ltd., Andover, UKSearch for more papers by this authorDarrell J. Triulzi, Darrell J. Triulzi Department of Pathology, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this authorPhilip C. Spinella, Philip C. Spinella orcid.org/0000-0003-1721-0541 Departments of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USASearch for more papers by this author First published: 07 July 2022 https://doi.org/10.1111/trf.17012Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. 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BACKGROUND:Based on previous experiments in nonhuman primates, we hypothesized that DO2 crit in humans is 5-6 ml O2 ·kg-1  min-1 .STUDY DESIGN AND METHODS:We measured the compensatory reserve (CRM) and calculated oxygen delivery (DO2 ) in 166 healthy, normotensive, nonsmoking subjects (97 males, 69 females) during progressive central hypovolemia induced by lower body negative pressure as a model of ongoing hemorrhage. Subjects were classified as having either high tolerance (HT; N = 111) or low tolerance (LT; N = 55) to central hypovolemia.RESULTS:HT and LT groups were matched for age, weight, BMI, and vital signs, DO2 and CRM at baseline. The CRM-DO2 relationship was best fitted to a logarithmic model in HT subjects (amalgamated R2  = 0.971) and a second-order polynomial model in the LT group (amalgamated R2  = 0.991). Average DO2 crit for the entire subject cohort was estimated at 5.3 ml O2 ·kg-1  min-1 , but was ~14% lower in HT compared with LT subjects. The reduction in DO2 from 40% CRM to 20% CRM was 2-fold greater in the LT compared with the HT group.CONCLUSIONS:Average DO2 crit in humans is 5.3 ml O2 ·kg-1  min-1 , but is ~14% lower in HT compared with LT subjects. The CRM-DO2 relationship is curvilinear in humans, and different when comparing HT and LT individuals. The threshold for an emergent monitoring signal should be recalibrated from 30% to 40% CRM given that the decline in DO2 from 40% CRM to 20% CRM for LT subjects is located on the steepest part of the CRM-DO2 relationship.

Based on limited published evidence, physiological principles, clinical experience, and expertise, the author group has developed a consensus statement on the potential for iatrogenic harm with rapid sequence induction (RSI) intubation and positive-pressure ventilation (PPV) on patients in hemorrhagic shock. "In hemorrhagic shock, or any low flow (central hypovolemic) state, it should be noted that RSI and PPV are likely to cause iatrogenic harm by decreasing cardiac output." The use of RSI and PPV leads to an increased burden of shock due to a decreased cardiac output (CO)2 which is one of the primary determinants of oxygen delivery (DO2). The diminishing DO2 creates a state of systemic hypoxia, the severity of which will determine the magnitude of the shock (shock dose) and a growing deficit of oxygen, referred to as oxygen debt. Rapid accumulation of critical levels of oxygen debt results in coagulopathy and organ dysfunction and failure. Spontaneous respiration induced negative intrathoracic pressure (ITP) provides the pressure differential driving venous return. PPV subsequently increases ITP and thus right atrial pressure. The loss in pressure differential directly decreases CO and DO2 with a resultant increase in systemic hypoxia. If RSI and PPV are deemed necessary, prior or parallel resuscitation with blood products is required to mitigate post intervention reduction of DO2 and the potential for inducing cardiac arrest in the critically shocked patient.

Background: Early application of tourniquets has reduced injury death rates. At the end of 2013, the Israel Defense Forces Medical Corps completed a military-wide introduction of the Combat Application Tourniquet as the standard-issued tourniquet. The accompanying clinical practice guideline encouraged combat soldiers and medical teams towards a liberal use of tourniquets for extremity injuries, even when in doubt. Objectives: This study aimed to assess the effects of the wide introduction of advanced tourniquets on the rate of tourniquet applications, the type of tourniquet applied, and the differences in hospitalisation outcomes following the introduction. Methods: The study population was composed of hospitalised military casualties with an extremity injury treated by military medical teams between 2006 and 2015. Prehospital data were extracted from the Israel Defense Forces Trauma Registry and matched to corresponding hospital data from the Israeli National Trauma Registry. Two periods were compared: 2006-2013 "pre-intervention period" and 2014-2015 "post-intervention period". Results: A total of 1,578 casualties were recorded during the study period. Of these, 320 (20.3%) occurred between 2014-2015. Characteristics of casualties in the post-intervention period were similar to those in the pre-intervention period including the rate of traumatic amputations (2.5% vs 2.2%, p = 0.93) and Injury Severity Score of 16 or above (12.8% vs 14.9%, p = 0.40). The rate of tourniquet application was more than four-fold in the post-intervention period compared to the pre-intervention period (22.8% vs 5.5%, p < 0.001). Nevertheless, rates of in-hospital amputations (1.6% vs 1.6%, p = 1.00) and death (0.9% vs 1.3%, p = 0.53) were similar in the two periods. Conclusion: Following the IDF military-wide introduction of advanced tourniquets, the tourniquet application rate rose sharply, the use of old tourniquets ceased over time, and in-hospital amputation rate did not increase. These findings suggest that the awareness for haemorrhage control using advanced tourniquets rose. (C) 2020 Elsevier Ltd. All rights reserved.

Treating hemorrhagic shock is challenging, the pathology is complex, and time is critical. Treatment requires resources in mental bandwidth (i.e., focused attention), drugs and blood products, equipment, and personnel. Providers must focus on treatment options in order of priority while also maintaining a dynamic assessment of the patient's response to treatment and considering potential differential diagnoses. In this process, the cognitive load is substantial. To avoid errors of clinical reasoning and practical errors of commission, omission, or becoming fixated, it is necessary to use evidence-based treatment recommendations that are concise, in priority order, and easily recalled. This is particularly the case in the austere, remote, or tactical environment. A simple mnemonic acronym, SMART, is presented in this article. It is a clinical heuristic that can be used as an aide-mémoire during the initial phases of resuscitation of the trauma patient with hemorrhagic shock: Start the clock and Stop the bleeding; Maintain perfusion; Administer antifibrinolytics; Retain heat; Titrate blood products and calcium; Think of alternative causes of shock.

Background:The rate of failing to apply a tourniquet remains high.Hypothesis:The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel.Methods:This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure >= 200mmHg; (2) time to stop bleeding <= 60 seconds; and (3) placement up to 7.5cm above the amputation.Results:Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, -17.283 to 23.404, -1.792 to 6.105, and 0.932 to 2.387, respectively). Tourniquet placement was incorrect in most of the applications (62.30%).Conclusions:This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.Tsur, AM, Binyamin, Y, Koren, L, Ohayon, S, Thompson; P, Glassberg, E. High tourniquet failure rates among non-medical personnel do not improve with tourniquet training, including combat stress inoculation: a randomized controlled trial. Prehosp Disaster Med. 2019;34(3):282-287.

ABSTRACT The Trauma Hemostasis and Oxygenation Research (THOR) Network has developed a consensus statement on the role of permissive hypotension in remote damage control resuscitation (RDCR). A summary of the evidence on permissive hypotension follows the THOR Network position on the topic. In RDCR, the burden of time in the care of the patients suffering from noncompressible hemorrhage affects outcomes. Despite the lack of published evidence, and based on clinical experience and expertise, it is the THOR Network’s opinion that the increase in prehospital time leads to an increased burden of shock, which poses a greater risk to the patient than the risk of rebleeding due to slightly increased blood pressure, especially when blood products are available as part of prehospital resuscitation. The THOR Network’s consensus statement is, “In a casualty with life-threatening hemorrhage, shock should be reversed as soon as possible using a blood-based HR fluid. Whole blood is preferred to blood components. As a part of this HR, the initial systolic blood pressure target should be 100 mm Hg. In RDCR, it is vital for higher echelon care providers to receive a casualty with sufficient physiologic reserve to survive definitive surgical hemostasis and aggressive resuscitation. The combined use of blood-based resuscitation and limiting systolic blood pressure is believed to be effective in promoting hemostasis and reversing shock”

BACKGROUND: The provision of transfusion support to isolated military or civilian projects may require the use of an emergency donor panel (EDP) for immediate warm fresh whole blood (WFWB). The aim of this short discussion article is to raise and resolve some of the practical aspects for the nonspecialist faced with the emergency collection of WFWB whole blood in the austere medical environment (AME).METHODS AND RESULTS: A proposed field EDP questionnaire and triage tool (QTT) is presented. It is designed for the hostile, remote, or austere environment that falls outside normal regulated supply of cold-stored blood products or removed from trained blood collection personnel, where collection may fall to an isolated medical provider. The tool has been drafted based on review of existing guidelines and consultation with practitioners. It serves as a point of reference for local guidelines and has yet to be validated.CONCLUSIONS: The use of the EDP is associated with risk; however, it remains the simplest method of providing rapid transfusion support. The best way to manage the risk is to brief and prescreen blood donors before deployment. An abbreviated donor QTT can be an aide to decision making at the time of donation. The tool should be tailored to requirements and underpinned by policy and training.

In planning for future contingencies, current problems often crowd out historical perspective and planners often turn to technological solutions to bridge gaps between desired outcomes and the reality of recent experience. The US Military, North Atlantic Treaty Organization, and other allies are collectively taking stock of 10-plus years of medical discovery and rediscovery of combat casualty care after the wars in Iraq and Afghanistan. There has been undeniable progress in the treatment of combat wounded during the course of the conflicts in Southwest Asia, but continued efforts are required to improve hemorrhage control and provide effective prehospital resuscitation that treats both coagulopathy and shock. This article presents an appraisal of the recent evolution in medical practice in historical context and suggests how further gains in far forward resuscitation might be achieved using existing technology and methods based on whole-blood transfusion while research on new approaches continues.