ECMO for combat casualties: current evidence, special considerations, and future directions

Extracorporeal membrane oxygenation (ECMO) has traditionally been used cautiously in trauma because of bleeding, coagulopathy, traumatic brain injury, and the need for repeated surgery. However, advances in venovenous ECMO (VV-ECMO), anticoagulation strategies, trauma critical care, and ECMO transport have broadened its potential role in selected trauma patients. Combat-related casualties represent a distinct subgroup: they are often young, previously healthy individuals with preserved cardiopulmonary reserve who may develop severe but potentially reversible respiratory or circulatory failure after penetrating, blast, thoracic, or polytraumatic injury. Current evidence supports ECMO as a feasible rescue strategy in selected trauma patients, particularly for refractory trauma-induced respiratory failure, although combat-specific data remain limited. In this review, we examine trauma-ECMO evidence and representative cases; patient selection; ECMO configuration; trauma-specific complications; care across military roles; contested evacuation; and resource allocation. Given the scarcity of combat-specific data, the proposed clinical and operational frameworks should be viewed as conceptual models rather than validated algorithms or consensus recommendations; ECMO should remain a highly selective, system-dependent rescue strategy rather than a routine battlefield therapy. Not applicable.