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This manuscript proposes the lethal pentagon: a time-aware extension of the lethal diamond in which duration is treated as the contextual variable that changes the meaning and reversibility of trauma physiology. Identical biochemical values may represent different clinical trajectories depending on whether they follow brief shock or prolonged hemorrhage. The framework is particularly relevant to prolonged casualty care, delayed evacuation, and trauma systems in which time to definitive hemorrhage control is uncertain. Future research and quality improvement should report when derangements occur, how long they persist, and how rapidly they resolve. Formalizing time may improve handover, triage, audit, and trauma system design.<\/jats:p>","DOI":"10.1093\/milmed\/usag364","type":"journal-article","created":{"date-parts":[[2026,7,23]],"date-time":"2026-07-23T11:52:34Z","timestamp":1784807554000},"source":"Crossref","is-referenced-by-count":0,"title":["The Lethal Pentagon: Time as the Central Driver of Trauma Physiology"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9568-0138","authenticated-orcid":false,"given":"Lars","family":"Veldhuis","sequence":"first","affiliation":[{"name":"Department of Anesthesiology, Erasmus MC , 3015 GD, Rotterdam,","place":["The Netherlands"]},{"name":"Department of Trauma Surgery, Erasmus MC , 3015 GD, Rotterdam,","place":["The Netherlands"]},{"name":"World Extreme Medicine (WEM) , Devon, EX13 5HU,","place":["United 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