Review Article

Transfusion Practice in Trauma Resuscitation

Authors: Ashley M. Eckel, MD, PhD, John R. Hess, MD


Recognition of the acute coagulopathy of trauma and the limits of reconstituting whole blood with conventional blood components has led to a radical change in the way trauma patients with severe injuries are resuscitated. Massive transfusion protocols (MTP) have evolved toward the administration of conventional blood components in fixed ratios. Administration of a 1:1:1 unit ratio of fresh frozen plasma to whole-blood–derived platelets to packed red blood cells is now the most common strategy and the stated goal of directors of >80% of the level I trauma centers in the United States. Various physiologic scoring systems exist to guide early activation of an MTP. After activation of an MTP, more goal-directed therapy follows as soon as laboratory results are available. Hemostatic resuscitation using defined blood component ratios modified by early laboratory results can lead to more efficient blood product usage and improved patient outcomes.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma 2006;60(6 Suppl):S3-S11.
2. Dutton RP, Stansbury LG, Leone S, et al. Trauma mortality in mature trauma systems: are we doing better? An analysis of trauma mortality patterns, 1997-2008. J Trauma 2010;69:620-626.
3. Armand R, Hess JR. Treating coagulopathy in trauma patients. Transfus Med Rev 2003;17:223-231.
4. Hess JR, Lindell AL, Stansbury LG, et al. The prevalence of abnormal results of conventional coagulation tests on admission to a trauma center. Transfusion 2009;49:34-39.
5. Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: Simple as ABC (assessment of blood consumption)? J Trauma 2009;66:346-352.
6. American College of Surgeons. ACS TQIP massive transfusion in trauma guidelines. Published 2013. Accessed June 7, 2017.
7. Yucel N, Lefering R, Maegele M, et al. Trauma associated severe hemorrhage (TASH)-score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 2006;60:1228-1237.
8. McLaughlin DF, Niles SE, Salinas J, et al. A predictive model for massive transfusion in combat casualty patients. J Trauma 2008;64(2 Suppl):S57-S63.
9. Baraniuk S, Tilley BC, del Junco DJ, et al. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury 2014;45:1287-1295.
10. Hussmann B, Lefering R, Waydhas C, et al. Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site. Injury 2013;44:611-617.
11. Cotton BA, Guy JS, Morris JA, Jr et al. The cellular, metabolic, and systemic consequences of aggressive fluid resuscitation strategies. Shock 2006;26: 115-121.
12. Brohi K, Singh J, Heron M, et al. Acute traumatic coagulopathy. J Trauma 2003;54:1127-1130.
13. MacLeod JB, Lynn M, McKenney MG, et al. Early coagulopathy predicts mortality in trauma. J Trauma 2003;55:39-44.
14. Hess JR, Brohi K, Dutton RP, et al. The coagulopathy of trauma: a review of mechanisms. J Trauma 2008;65:748-754.
15. Waters JH, Gottlieb A, Schoenwald P, et al. Normal saline versus lactated Ringer's solution for intraoperative fluid management in patients undergoing abdominal aortic aneurysm repair: an outcome study. Anesth Analg 2001;93: 817-822.
16. US Department of Defense. Shock and Resuscitation. Controlled Resuscitation in Emergency War Surgery. Washington, DC:Department of the Army, Office of the Surgeon General, Borden Institute, 2004.
17. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62:307-310.
18. AABB. Standards for a Patient Blood Management Program. 1st ed. Bethesda MD: AABB Press; 2014.
19. Zink KA, Sambasivan CN, Holcomb JB, et al. A high ratio of plasma and platelets to packed red blood cells in the first 6 hours of massive transfusion improves outcomes in a large multicenter study. Am J Surg 2009;197:565-570.
20. Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg 2013;148:127-136.
21. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA 2015;313:471-482.
22. Kornblith LZ, Howard BM, Cheung CK, et al. The whole is greater than the sum of its parts: hemostatic profiles of whole blood variants. J Trauma Acute Care Surg 2014;77:818-827.
23. Murphy CH, Hess JR. Massive transfusion: red blood cell to plasma and platelet unit ratios for resuscitation of massive hemorrhage. Curr Opin Hematol 2015;22:533-539.
24. Cooling L. Going from A to B: the safety of incompatible group A plasma for emergency release in trauma and massive transfusion patients. Transfusion 2014;54:1695-1697.
25. Yazer M, Eder AF, Land KJ. How we manage AB plasma inventory in the blood center and transfusion service. Transfusion 2013;53:1627-1633.
26. Novak DJ, Bai Y, Cooke RK, et al. Making thawed universal donor plasma available rapidly for massively bleeding trauma patients: experience from the Pragmatic, Randomized Optimal Platelets and Plasma Ratios (PROPPR) trial. Transfusion 2015;55:1331-1339.
27. Zielinski MD, Johnson PM, Jenkins D, et al. Emergency use of prethawed Group A plasma in trauma patients. J Trauma Acute Care Surg 2013;74:69-75.
28. CRASH-2 trial collaborators, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010;376:23-32.
29. Morrison JJ, Dubose JJ, Rasmussen TE, et al. Military Application of Tranexamic Acid in Trauma Emergency Resuscitation (MATTERs) study. Arch Surg 2012;147:113-119.
30. Tummala R, Kavtaradze A, Gupta A, et al. Specific antidotes against direct oral anticoagulants: a comprehensive review of clinical trials data. Int J Cardiol 2016;214:292-298.
31. Goodnough LT, Levy JH. The judicious use of recombinant factor VIIa. Semin Thromb Hemost 2016;42:125-132.
32. Boffard KD, Riou B, Warren B, et al. Recombinant factor VIIa as adjunctive therapy for bleeding control in severely injured trauma patients: two parallel randomized, placebo-controlled, double-blind clinical trials. J Trauma 2005;59:8-18.
33. Levi M, Levy JH, Andersen HF, et al. Safety of recombinant activated factor VII in randomized clinical trials. N Engl J Med 2010;363:1791-1800.
34. Simpson E, Lin Y, Stanworth S, et al. Recombinant factor VIIa for the prevention and treatment of bleeding in patients without haemophilia. Cochrane Database Syst Rev 2012;3:CD005011.
35. Rourke C, Curry N, Khan S, et al. Fibrinogen levels during trauma hemorrhage, response to replacement therapy, and association with patient outcomes. J Thromb Haemost 2012;10:1342-1351.
36. Charbit B, Mandelbrot L, Samain E, et al. The decrease of fibrinogen is an early predictor of the severity of postpartum hemorrhage. J Thromb Haemost 2007;5:266-273.
37. Steinmetz J, Sorensen AM, Henriksen HH, et al. Pilot Randomized trial of Fibrinogen in Trauma Haemorrhage (PRooF-iTH): study protocol for a randomized controlled trial. Trials 2016;17:327.