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EMA Cited · Resuscitation · Trauma

Massive transfusion

Updated Oct 24, 2026Adults · trauma · ED management14 sources · 13 checked in PubMed2 figuresEuropean trauma bleeding guideline 2023

Bottom line

  • Decide early, using the whole picture. Combine physiology, injury pattern, mechanism and the response to resuscitation. Use the shock index and pulse pressure to judge how much blood the patient will need.1
  • Give plasma and platelets with the red cells. In PROPPR, 1:1:1 did not lower mortality compared with 1:1:2, but fewer patients bled to death in 24 hours (9.2% vs 14.6%).2 The guideline wants plasma to red cells of at least 1:2, or fibrinogen with red cells.1
  • Tranexamic acid within 3 hours: 1 g over 10 minutes, then 1 g over 8 hours.1 In CRASH-2, it helped most within 1 hour, and after 3 hours it raised the risk of death from bleeding.3
  • Keep ionized calcium normal. Each unit of red cells or plasma carries about 3 g of citrate. Correct calcium with calcium chloride.1
  • Accept a lower blood pressure until the bleeding stops: systolic 80–90 mm Hg. In severe brain injury, keep the MAP at 80 or higher.1

Who needs it

Massive transfusion means replacing more than one blood volume in 24 hours, or more than half of it in 4 hours. An adult's blood volume is about 70 mL/kg.4 Don't wait for that definition to be met. Activate when you expect it.4,1

  • Shock index (heart rate ÷ systolic BP) is normally 0.5–0.7. Values of 0.9–1.0 or higher were associated with massive transfusion.1 Across 35 studies, it was 68% sensitive and 84% specific, too weak to use alone.5
  • Narrow pulse pressure under 30 mm Hg was associated with massive transfusion (OR 3.74).1
  • Mechanism: falls from 6 m (20 ft) or more, entrapment, and high-energy impacts point to major bleeding.1
  • Repeat the hemoglobin. A normal first value can hide early bleeding.1
  • Lactate, or base deficit if lactate isn't available, tracks bleeding and hypoperfusion.1
ABC score: 1 point eachPresent?
Penetrating mechanism+1
Positive FAST+1
Arrival systolic BP ≤ 90 mm Hg+1
Arrival heart rate ≥ 120/min+1

A score of 2 or more was 75% sensitive and 86% specific for massive transfusion in the derivation cohort (n = 596).6 The guideline notes that no prediction score is in widespread use, and none has strong prospective validation.1

First 15 minutes

  1. Stop the bleeding you can reach. Press on open wounds. Use a tourniquet for life-threatening limb bleeding, and a pelvic binder for a suspected pelvic fracture.1
  2. Activate the massive transfusion protocol and call for definitive control. An obvious source, or shock in extremis with a likely source, needs an immediate bleeding-control procedure.1
  3. Give tranexamic acid if you are within 3 hours of injury. Don't wait for a viscoelastic test.1
  4. Transfuse in ratio: plasma and red cells at least 1:2, or fibrinogen (or cryoprecipitate) with red cells, plus a high platelet ratio.1
  5. Limit crystalloid. Target systolic 80–90 mm Hg until bleeding is controlled. Add norepinephrine if fluids alone don't reach the target.1
  6. Send labs now and repeat them: PT/INR, Clauss fibrinogen, platelets, and viscoelastic testing if you have it. Check ionized calcium on the blood gas.1
  7. Warm the patient and keep warming. Remove wet clothing.1
FIG 1The tranexamic acid window. Drawn for this page. Time zero is the injury. Relative risk of death from bleeding in CRASH-2 by time to treatment: 0.68 within 1 hour, 0.79 at 1–3 hours, and 1.44 after 3 hours.3 The guideline dose is a 1 g bolus over 10 minutes, then 1 g over 8 hours.1

Products and doses

AgentAdult doseWhen
Antifibrinolytic
Tranexamic acid1 g IV over 10 min, then 1 g over 8 hBleeding or at risk, within 3 h of injury (grade 1A).1
Coagulation
Fibrinogen3–4 g first dose: 15–20 single-donor units of cryoprecipitate, or 3–4 g of concentrateMajor bleeding with fibrinogen ≤ 1.5 g/L (150 mg/dL) or a viscoelastic deficit.1
Platelets4–8 single units, or 1 apheresis packKeep above 50,000/µL; above 100,000/µL with brain injury.1
Plasma (after the first round)Guided by labsPT or APTT more than 1.5 times normal, or a viscoelastic factor deficit.1
Calcium chloride 10%10 mL contains 270 mg calciumPreferred for low ionized calcium. 10 mL of 10% gluconate holds only 90 mg.1
Anticoagulant reversal
WarfarinPCC plus vitamin K 5–10 mg IVEarly, in any bleeding trauma patient (grade 1A).1
DabigatranIdarucizumab 5 g IVLife-threatening bleeding.1
Apixaban, rivaroxabanAndexanet alfa, or PCC 25–50 U/kgLife-threatening bleeding. PCC if andexanet is unavailable, or for edoxaban.1

Unreviewed doses. Verify against the current label and your institution's protocol before giving anything.

Doses from the European guideline text.1 Recombinant factor VIIa is not first-line; consider it only when everything else has failed.1 Don't give routine platelets just because a bleeding patient takes antiplatelet drugs.1

Targets once labs are back

MeasureTarget
Systolic BP, no brain injury80–90 mm Hg (MAP 50–60) until bleeding stops1
MAP, severe brain injury (GCS ≤ 8)≥ 80 mm Hg1
Hemoglobin, if transfusing7–9 g/dL1
FibrinogenTreat at ≤ 150 mg/dL (1.5 g/L)1
Platelets> 50,000/µL; > 100,000/µL with brain injury1
Ionized calciumNormal, 4.4–5.2 mg/dL (1.1–1.3 mmol/L)1
TemperatureNormothermia, 36–37 °C1
Sources disagree

Fibrinogen threshold: the European guideline treats at 1.5 g/L (150 mg/dL) or below.1 LITFL's protocol summary aims only to keep fibrinogen at 1.0 g/L or above.4 Follow your local protocol.

What the trials show

  • PROPPR (n = 680): 1:1:1 vs 1:1:2 plasma, platelets and red cells. Mortality at 24 hours was 12.7% vs 17.0%, and at 30 days 22.4% vs 26.1%. Neither difference was significant. Hemostasis was more common with 1:1:1 (86% vs 78%), and exsanguination deaths fell (9.2% vs 14.6%). Complications did not differ.2
  • CRASH-2 (n = 20,211): tranexamic acid lowered all-cause mortality (14.5% vs 16.0%) and death from bleeding (4.9% vs 5.7%).7
  • PATCH-Trauma (n = 1,310): prehospital tranexamic acid did not improve survival with a good functional outcome at 6 months (53.7% vs 53.5%). Death at 28 days was lower (17.3% vs 21.8%), a secondary outcome.8
  • CRYOSTAT-2 (n = 1,604): early, empiric high-dose cryoprecipitate added to standard care did not change 28-day mortality (25.3% vs 26.1%).9

Before hospital, and whole blood

  • PAMPer (n = 501): thawed plasma during air transport lowered 30-day mortality (23.2% vs 33.0%).10
  • RePHILL (n = 432): red cells plus freeze-dried plasma were no better than saline for a composite of death or poor lactate clearance. The trial stopped early because of COVID-19.11
  • Whole blood vs components, before hospital (n = 1,020): 30-day mortality was 25.9% vs 20.5%, not significantly different.12
  • Whole blood, pooled data (40 studies, 38 of them observational): civilian patients had lower 24-hour mortality (OR 0.73), with wide variation between studies.13
Sources disagree

Prehospital blood: PAMPer found a mortality benefit and RePHILL did not, so the European guideline makes no recommendation either way.10,11,1 Whole blood looks better than components in mostly observational data, but the one large prehospital randomized trial found no benefit.13,12

A labelled bag of donated whole blood with coiled tubing on a steel bench, a gloved hand sealing the tubing
FIG 2A unit of whole blood. One bag holds red cells, plasma and platelets together, in citrate anticoagulant. Its place in civilian trauma is still being tested.12,13Vegasjon · Wikimedia Commons · CC BY-SA 4.0

Complications to watch

  • Low calcium: citrate in each unit binds calcium, and a shocked liver clears it slowly. Correct ionized calcium below 0.9 mmol/L (3.6 mg/dL) promptly. Below 0.8 mmol/L, arrhythmias become more likely.1
  • In 7,431 trauma patients, 9.8% developed severe hypocalcemia within 48 hours. More red cell units independently predicted it, and it was associated with death.14
  • No trial yet shows that treating low calcium improves survival.1
  • Hypothermia impairs clotting; each 1 °C drop cuts coagulation factor function by about 10%. Lab clotting tests run at 37 °C will miss this.1
  • Also expect high potassium, citrate-related alkalosis, and transfusion lung injury. Check labs every 30–60 minutes during massive transfusion.4

Pitfalls

  • Waiting for a low hemoglobin. The first value can be normal while the patient bleeds.1
  • Starting tranexamic acid more than 3 hours after injury.3,1
  • Running red cells alone for the first several units. Plasma belongs in the first round, with a high platelet ratio.1,2
  • Forgetting calcium, or replacing it with gluconate ampules that hold a third of the calcium in chloride.1
  • Applying permissive hypotension to a patient with severe brain injury.1
  • Letting the patient get cold in the resuscitation bay.1

How strong is the evidence?

Tranexamic acid within 3 hours and warfarin reversal carry grade 1A recommendations.1 The product ratio, fibrinogen, platelet and calcium recommendations are graded 1C or 2, and the guideline calls the ratio data equivocal.1 PROPPR missed its mortality endpoints.2 Prediction scores are mostly retrospective.1,5

On-shift teaching

Questions to ask a learner at the bedside. Tap a question to see the answer. Every answer uses facts cited above.

Q1What are the four items of the ABC score, and what score triggers concern?
Penetrating mechanism, positive FAST, arrival systolic BP ≤ 90, and heart rate ≥ 120. A score of 2 or more was 75% sensitive and 86% specific.6
Q2Did PROPPR show that 1:1:1 saves lives?
Not on its primary outcomes. Mortality at 24 hours and 30 days did not differ significantly. But more patients reached hemostasis (86% vs 78%) and fewer bled to death (9.2% vs 14.6%).2
Q3A patient arrives 4 hours after injury. Should you start tranexamic acid?
No. In CRASH-2, treatment after 3 hours increased the risk of death from bleeding (RR 1.44).3 The guideline limits it to the first 3 hours.1
Q4Why does massive transfusion lower calcium, and which salt should you give?
Each unit of red cells or plasma carries about 3 g of citrate, which binds calcium, and a shocked liver clears it slowly. Give calcium chloride: 10 mL of 10% holds 270 mg of calcium vs 90 mg in gluconate.1
Q5What blood pressure do you target before the bleeding is controlled?
Systolic 80–90 mm Hg (MAP 50–60). With severe brain injury, keep the MAP at 80 or higher.1
Q6How much fibrinogen do you give, and when?
When fibrinogen is 1.5 g/L (150 mg/dL) or lower with major bleeding, give 3–4 g: 15–20 single-donor units of cryoprecipitate, or 3–4 g of concentrate.1

References

Evidence base

What this page is built on

14 sources, cited 80 times. Dots are sources, filled by how far each was read; stronger color means a larger share of the citations. Tap a tier to see its sources.

Read in full · 2Abstract read · 12Record only · 0Link checked · 0

Checked by the writer, not a physician. The dots show how each source was read, not that anyone has confirmed the claims.

How this page was made
  • Written from scratch. No source text was copied; facts are restated and cited.
  • Anchored on the 2023 European guideline on major bleeding and coagulopathy after trauma, read in full through Europe PMC. Recommendation grades are quoted from it. Doses come from the guideline text.
  • Each PubMed citation was resolved through NCBI E-utilities and each number checked against that paper's abstract.
  • Adults with traumatic bleeding. Massive transfusion in obstetric, gastrointestinal or surgical bleeding, and in children, is not covered here.
  • Figure 1 was drawn for this page from cited data. Figure 2 is an openly licensed image from Wikimedia Commons, credited under it, and keeps its own license.
  • Not for clinical use.
Not for clinical use

AI-generated draft. Not reviewed by a physician. This page is for education only and may contain errors, including in doses. Do not use it to diagnose, treat or make decisions about any patient. Rely on your own clinical judgment, your institution's protocols and current drug labeling. Reading this page does not create a physician-patient relationship. Full terms