Hemostatic Resuscitation in Trauma-Induced Coagulopathy: A Comprehensive Narrative Review

Background and Objectives: Traumatic hemorrhage remains the leading cause of preventable death following major injury, with most hemorrhage-related fatalities occurring within the first hours after trauma. During this early phase, trauma-induced coagulopathy (TIC) frequently develops as an independent pathophysiological response, affecting up to one-third of severely injured patients and being strongly associated with increased morbidity and mortality. Over the past two decades, TIC has been recognized as a complex endogenous process rather than a simple consequence of dilution, hypothermia, or acidosis, prompting a paradigm shift in early trauma resuscitation. Materials and Methods: This narrative review analyzes the current literature on the pathophysiology of TIC and the evolution of hemostatic resuscitation strategies. Key topics include the mechanisms underlying early coagulopathy, its clinical impact, and the evidence supporting contemporary therapeutic approaches. Published data on balanced transfusion strategies, whole blood transfusion, fibrinogen replacement, cryoprecipitate, prothrombin complex concentrates, tranexamic acid and viscoelastic-guided resuscitation were reviewed, along with relevant international guidelines. Results: Emerging evidence supports early, balanced, and targeted hemostatic resuscitation to mitigate the effects of TIC and improve outcomes in bleeding trauma patients. Balanced transfusion ratios, prompt correction of fibrinogen deficiency, early antifibrinolytic therapy and selective use of coagulation factor concentrates have been associated with reduced transfusion requirements and improved survival. Viscoelastic testing enables rapid, individualized assessment of coagulation abnormalities, although its availability and implementation remain inconsistent across trauma systems. Conclusions: Early recognition and aggressive, structured management of trauma-induced coagulopathy are essential to reduce preventable deaths from traumatic hemorrhage. While advances in hemostatic resuscitation have improved outcomes, significant challenges remain in standardizing treatment protocols and expanding access to viscoelastic diagnostics. Ongoing research and system-level optimization are needed to further refine and disseminate evidence-based strategies for the management of TIC.