What is the recommended massive transfusion protocol in trauma patients?

From the Guidelines

The recommended massive transfusion protocol in trauma patients involves a balanced 1:1:1 ratio of packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets, as evidenced by the most recent and highest quality study 1. This approach is supported by the European Society of Intensive Care Medicine's clinical practice guideline, which suggests that high transfusion ratios ranging from 1:1 to 1:2 FFP:RBC result in a large mortality benefit early on and at 30 days 1. The protocol is usually activated when a patient is anticipated to require more than 10 units of blood products within 24 hours or 4 units within 1 hour. Key components of the protocol include:

• Administering 1 gram of tranexamic acid (TXA) IV over 10 minutes within 3 hours of injury, followed by 1 gram over 8 hours, to reduce fibrinolysis and decrease mortality
• Calcium replacement with 1 gram of calcium chloride or 3 grams of calcium gluconate when calcium levels fall below normal or after every 4 units of blood products
• Cryoprecipitate (10 units or 2 pools) administration when fibrinogen levels fall below 150-200 mg/dL
• Temperature management with all fluids warmed to prevent hypothermia
• Point-of-care testing, including thromboelastography (TEG) or rotational thromboelastometry (ROTEM), to guide specific component therapy 1. This balanced approach addresses the triad of hypothermia, acidosis, and coagulopathy that occurs in trauma, improving survival by providing appropriate clotting factors and cellular components to maintain hemostasis while supporting oxygen delivery. The use of a 1:1:1 ratio may be modified according to laboratory values, and point-of-care tests can be utilized to obtain a rapid assessment of hemostasis and assist in clinical decision-making 1.

From the Research

Massive Transfusion Protocol in Trauma Patients

• The recommended massive transfusion protocol in trauma patients involves the transfusion of a minimum of 3-4 packed red blood cells within 1 hour 2.
• Current literature defines massive transfusion as the transfusion of a large amount of blood products in a short period, with the goal of restoring circulating volume and preventing coagulopathy 2, 3.
• The use of standard laboratory and/or viscoelastic tests can help guide the diagnosis and treatment of trauma-induced coagulopathy, with a focus on early hemorrhage control and substitution of substantiated deficiencies 2.

Blood Product Ratios

• The optimal ratio of blood products, including plasma, platelets, and red blood cells, is still a topic of debate, but current evidence suggests that a balanced transfusion ratio of 1:1:1 or 1:1:2 is recommended 4, 5, 3.
• A study published in 2020 found that massive transfusion protocols using a balanced transfusion ratio were effective in decreasing mortality and improving outcomes in trauma patients 3.
• Another study published in 2008 found that a 1:1 fresh frozen plasma to packed red blood cells ratio reduced life-threatening coagulopathy, but did not translate into a survival benefit 5.

Adjuncts and Timing of Transfusion

• Adjuncts such as tranexamic acid, fibrinogen concentrate, and prothrombin complex may be used in addition to blood products to help control bleeding and prevent coagulopathy 2, 6.
• The timing of transfusion is critical, with faster delivery of blood products associated with better outcomes 6, 3.
• A study published in 2024 found that patients who received more than 3 units of packed red blood cells with at least 1 unit of fresh frozen plasma and/or platelets had improved survival and reduced complications compared to those who received packed red blood cells alone 6.

Conclusion is not allowed, so the response will continue with more subheadings and bullet points if needed.

Additional Considerations

• The use of whole blood is also possible as an alternative to component therapy 2.
• Massive transfusion protocols should be individualized to each patient's needs, taking into account their underlying coagulopathy and bleeding pattern 2, 3.
• Further research is needed to continue to refine and improve massive transfusion protocols in trauma patients 2, 5, 3.