Viscoelastic-Guided Hemostatic Resuscitation in Trauma: From Endothelial Endotype to System-Level Precision

Trauma-induced coagulopathy (TIC) is a biologically heterogeneous and rapidly evolving response to severe injury characterized by endothelial dysfunction, dysregulated thrombin generation, platelet impairment, and divergent fibrinolytic phenotypes. While balanced transfusion strategies have improved early hemorrhage control, they do not fully account for the phenotypic variability observed in TIC. Viscoelastic hemostatic assays (VHA), including thromboelastography and rotational thromboelastometry, provide real-time assessment of clot formation, strength, and fibrinolysis, enabling targeted hemostatic resuscitation. However, randomized trials have demonstrated improvements in transfusion targeting without consistent reductions in overall mortality. This structured narrative review synthesizes contemporary evidence on the biological mechanisms of TIC, fibrinolytic endotypes, and the role of viscoelastic testing in trauma resuscitation. A systematic search of PubMed/MEDLINE, Scopus, and Web of Science from January 2000 to February 2026 was performed, prioritizing landmark randomized trials, mechanistic studies, and international guidelines. The literature suggests that the effectiveness of VHA-guided resuscitation is influenced not only by diagnostic capability but also by the interaction between biological phenotype, timing of intervention, and trauma system performance. A hybrid model integrating early empiric balanced transfusion with subsequent phenotype-guided calibration may represent the most physiologically coherent strategy. Ultimately, viscoelastic testing should be understood as a decision-support modality embedded within mature trauma systems rather than a standalone determinant of survival. Future research should focus on phenotype-stratified clinical trials and system-integrated approaches capable of translating hemostatic precision into consistent outcome improvement.