In 1714, the satirist Jonathan Swift stated that the "blessing of liberty" must be paid for in "blood and treasure". As we look to events in Ukraine, the terrible price of freedom again becomes apparent. Yet war has also been the impetus for improvements in medical care, from Jean-Louis Petit's screw tourniquet and Dominique Larrey's ambulance volante to the modern concept of damage control resuscitation (DCR). Contemporary DCR is characterised by haemostatic resuscitation, permissive hypotension, and damage control surgery, which originated on the battlefield and is now entrenched in civilian practice. It is predicated on the ability to provide massive transfusion, and protocols ensure high volumes of universal donor blood products (eg, packed red cells, plasma, platelets, and cryoprecipitate) are transfused in prespecified ratios, along with pharmaceutical adjuncts such as calcium and tranexamic acid plus point of care viscoelastic testing for duced coagulopathy. Delay in initiating massive transfusion has been shown to worsen survival, and more recently, fresh whole blood has been used for trauma resuscitation of combat casualties. The United States Defense Committee on Trauma, Armed Services Blood Program, and Joint Trauma System have reached consensus that whole blood is the product of choice for resuscitation following traumatic haemorrhagic shock.
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