Challenges and possibilities in forward resuscitation.

The environmental and logistical constraints of the prehospital setting make it a challenging place for the treatment of trauma patients. This is perhaps more pronounced in the management of battlefield casualties before extraction to definitive care. In seeking solutions, interest has been renewed in implementing damage control resuscitation principles in the prehospital setting, a concept termed remote damage control resuscitation. These developments, while improving conflict survival rates, are not exclusive to the military environment, with similar situations existing in the civilian setting. By understanding the pathophysiology of shock, particularly the need for oxygen debt repayment, improvements in the assessment and management of trauma patients can be made. Technology gaps have previously hampered our ability to accurately monitor the prehospital trauma patient in real time. However, this is changing, with devices such as tissue hemoglobin oxygen saturation monitors and point-of-care lactate analysis currently being refined. Other monitoring modalities including newer signal analysis and artificial intelligence techniques are also in development. Advances in hemostatic resuscitation are being made as our understanding and ability to effectively monitor patients improve. The reevaluation of whole-blood use in the prehospital environment is yielding favorable results and challenging the negative dogma currently associated with its use. Management of trauma-related airway and respiratory compromise is evolving, with scope to improve on currently accepted practices. The purpose of this review is to highlight the challenges of treating patients in the prehospital setting and suggest potential solutions. In doing so, we hope to maintain the enthusiasm from people in the field and highlight areas for prehospital specific research and development, so that improved rates of casualty survival will continue.