Initial management of haemorrhagic war casualties: tactical priorities and innovative approaches in modern and future warfare.

backgroundHaemorrhage remains the leading cause of preventable death in modern armed conflict, affecting both combatants and civilians. Recent conflicts-particularly the ongoing conflict in Ukraine- have highlighted the increasing complexity of battlefield injuries, characterised by hybrid warfare, disrupted evacuation chains, and delayed access to definitive surgical care. These realities challenge traditional trauma paradigms, such as the "Golden Hour" and demand adaptation of haemorrhage control and resuscitation strategies to austere environment. CONTENT: This narrative review synthesizes current practices and emerging innovations in the initial management of haemorrhagic shock in combat. Immediate haemorrhage control techniques-such as tourniquets, pelvic binders, direct vessel clamping, and external or endovascular aortic occlusion-are examined for their tactical relevance and impact on survival. The review underscores the role of haemostatic dressings and both topical and injectable haemostatic agents in controlling non-compressible bleeding. Damage control resuscitation centres on early administration of blood products in a 1:1:1 ratio or when available, low‑titer group O whole blood (LTOWB), combined with permissive hypotension and prevention of hypothermia. Whole blood and LTOWB are now routinely used by several armed forces, particularly the US and French armies, simplifying logistics and improving haemostatic efficacy during prehospital and tactical resuscitation. In cases of major haemorrhage, a transfusion protocol can be facilitated by novel products, such as leucocyte-depleted whole blood and freeze-dried blood products. Tranexamic acid, when administered within the first three hours after injury, halves mortality in massively transfused casualties, consistent with major international guidelines. Operational innovations address evacuation delays: forward damage-control surgery by lightweight Role 1/2 teams; drone delivery of blood components and medicines over distances from short range to>100 km, depending on platform capability and regulatory clearance; and prototype drone platforms for casualty evacuation (CASEVAC). Advanced technologies-such as closed-loop fluid systems, digital-twin physiology models, and AI-assisted triage-are poised to standardise care and reduce cognitive load for providers in austere settings.

conclusionThe integration of haemorrhage control, targeted resuscitation, and logistical innovation defines the modern approach to managing war-related haemorrhagic shock. While challenges remain in evidence generation and field implementation, emerging practices-grounded in operational experience-are progressively improving survival. Ongoing investment in research, training, and technological adaptation will be essential to reducing preventable deaths on future battlefields.