Blood Product Ratios Research Articles

Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007-2015) or TNCs (2015-2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.

Minimizing Time to Plasma Administration and Fresh Frozen Plasma Waste: A Multimodal Approach to Improve Massive Transfusion at a Level 1 Trauma Center.

Massive transfusion protocols are part of damage control resuscitation for hemorrhaging trauma patients with the goal of returning the patient to hemodynamic stability. It is essential that patients receive blood products immediately and in the proper ratios. At our metropolitan Level 1 trauma center, we identified several challenges to deploying massive transfusion rapidly and within the recommended ratio guidelines. In 2016, we implemented a quality improvement project addressing 4 opportunities: fresh frozen plasma (FFP) bag breakage, plasma options, blood bank equipment, and multidisciplinary policy revision. Implementing packaging and shipping improvements, utilization of new products, and updating protocols have resulted in a 50% decrease in FFP bag breakage rates, a dramatic decrease in time for patients receiving massive transfusion to receive plasma products (mean time 3.5 min), and patients being administered the recommended ratio of blood products.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion.

To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. None. Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83). Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Massive transfusion in the pediatric population: A systematic review and summary of best-evidence practice strategies.

Pediatric patients require massive transfusion (MT) in a variety of settings. Multiple studies of adult MT support balanced ratio transfusion to improve outcomes; however, it is unclear if these findings can be extrapolated to pediatric populations. The use of balanced transfusion ratios, MT protocols, hemostatic adjuncts, and even the definition of a MT in children are all open questions. This review presents details of care from current practices in pediatric MT and summarizes practice strategies while providing insight from our single-center experience. PubMed, EMBASE, and Web of Science were searched using MeSH index and free-text terms for articles from 1946 to 2017. Articles were independently reviewed by two reviewers. Studies were assessed for definition of MT, factors predicting MT, MT complications, blood product ratios, hemostatic adjuncts, protocol logistics, and clinical outcomes. A heterogeneous composite of 29 articles was included in the analysis. Of these, 45% reported a formal transfusion protocol or adopted one during the study. Seven unique definitions of pediatric MT were reported; the most common was >1 total blood volume within 24 hours. A total of 18,369 patients were assessed, and 1,163 received MT (6.3%). Overall mortality for patients requiring MT in studies reporting mortality was high (range 14.7% to 51.2%). We identified 14 patients receiving MT at our center with an age range of 8 months to 18 years and average transfusion of 38.1 mL/kg red blood cells (range: 22.1 mL/kg to 156.7 mL/kg). Current practices of pediatric MT demonstrate a variety of site-specific interventions with a persistently high mortality rate. A national focus on improving techniques of MT in children has the potential to save the lives of these children. Systematic review, levels IV and V.

Computer simulation of transfusion with different blood product ratios in modern massive transfusion protocols

Modern massive transfusion protocols call for early plasma and platelets to patients presenting with hemorrhagic shock. The packed red blood cell (PRBC):plasma:platelet ratio generally ranges from 1:1:1 to 3:1:1, but the ideal ratio remains controversial. We aimed to determine the effects of different resuscitation strategies and blood product ratios on hematocrit, platelet and fibrinogen concentrations (FC) during resuscitation. Assuming: pre-insult blood volume 5 L; hematocrit 0.4, FC = 100%, platelet count 400 × 109/L; predetermined constant values for each blood product unit (volume, hematocrit, FC, platelet number); and transfusion rate to maintain euvolemia, we simulated different resuscitation strategies using a computer-based hemorrhage model. When crystalloids are administered to restore an acute 30% blood loss, the initial hematocrit, platelets and FC are adequate, and remain physiologic when further resuscitation is carried out with 1:1:1. Higher transfusion ratios increase the hematocrit at the expense of proportional drops in FC and platelets. When crystalloids and PRBCs (1500 mL) are administered to restore an acute 60% blood loss, the FC drops to 39%. Further resuscitation with 1:1:1 (but not with 2:1:1 or 3:1:1) increases the FC while maintaining the hematocrit and platelets within physiologic range. When blood products (1–3:1:1) are administered to restore an acute 60% blood loss, the initial hematocrit, platelets and FC are at adequate levels, but remain within physiologic range only when 1:1:1 (but not 2:1:1 or 3:1:1) is implemented for further resuscitation. Notably, platelet concentration consistently drops in all simulated scenarios reaching dangerously low levels particularly with high blood loss/transfusion rates and with higher transfusion ratios. The FC does not always drop by the same proportion with higher ratios probably because it is based on plasma concentration and is thus “cushioned” by the reduction in plasma volume as the hematocrit rises with higher transfusion ratios. In summary, computer simulation suggests that in non-severe shock hemorrhage, the differences between 1-3:1:1 transfusion ratios during initial resuscitation may be small. In severe shock, however, 1:1:1 results in the most physiologic hematocrit, FC and platelet concentration and is, therefore, desirable.

Analysis of Transfusion Volumes in the Elderly Trauma Population

Background: Blood transfusion and old age have been independently associated with worse outcomes and higher mortality in the trauma population. Determining specific volumes and ratios of blood products for the elderly population, a special population with varied hemodynamic responses to traumatic injury, is a challenge. This study was aimed at delineating the relationship between specific transfusion volumes and mortality with an ultimate goal of finding an optimal threshold where risk outweighs benefit. Methods: A retrospective study of data from patients aged 65 and older at a level II urban trauma center was conducted. All patients who were included in the study presented to the emergency department between January 2013 and January 2016 and received a blood product transfusion (n = 93). The primary outcome was defined as mortality 24 h after transfusion, while the secondary outcome measured was length of hospital stay. Optimal cut-off points were estimated using Youden J coefficients, and Cox proportional hazard ratio (HR) was performed to calculate mortality risk. Results: Patients receiving less than 5 units of blood product had a shorter length of stay (5.19 days) and decreased risk of mortality (HR = 2.48, P = 0.01). Patients receiving &gt;= 5 units of a blood product had a statistically significant increase in risk of mortality (HR = 6.207, P &lt; 0.001) and length of hospital stay (12.47 days), regardless of injury severity score. The administration of fresh frozen plasma was also an independent predictor of mortality. Patients who received a plasma transfusion had an increased risk of mortality (HR = 3.25, P &lt; 0.001). Conclusion: In this study, a threshold point of greater than 5 units of blood products has been associated with increased mortality and length of hospital stay. A more restrictive transfusion strategy has potential for improved outcomes. J Curr Surg. 2019;9(4):45-50 doi: https://doi.org/10.14740/jcs392

Lesson from the Battlefield: High Ratio of Blood Products During Massive Transfusion Reduces Operative Mortality in Cardiac Surgery: Results of a Society of Thoracic Surgeons National Database Study

Lesson from the Battlefield: High Ratio of Blood Products During Massive Transfusion Reduces Operative Mortality in Cardiac Surgery: Results of a Society of Thoracic Surgeons National Database Study

What's New in SHOCK, September 2018?

What's New in SHOCK, September 2018?

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children

BackgroundMassive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear. Material and methodsA retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios. ResultsThere were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups. ConclusionsA high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Optimal Dose, Timing and Ratio of Blood Products in Massive Transfusion: Results from a Systematic Review

Optimal dose, timing and ratio to red blood cells (RBC) of blood component therapy (fresh frozen plasma [FFP], platelets, cryoprecipitate or fibrinogen concentrate) to reduce morbidity and mortality in critically bleeding patients requiring massive transfusion is unknown. We performed a systematic review for randomized controlled trials (RCT) in MEDLINE, The Cochrane Library, Embase, CINAHL, PubMed the Transfusion Evidence Library and using multiple clinical trials registries to 21 February 2017. Sixteen RCTs were identified: six completed (five in adult trauma patients, one pediatric burn patients) and ten ongoing trials. Of the completed trials: three were feasibility trials, comparing a FFP, platelets and RBC ratio of 1:1:1 to laboratory-guided transfusion practice [n=69], early cryoprecipitate compared to standard practice [n=41], and early fibrinogen concentrate compared to placebo [n=45]; one trial compared the effect of FFP, platelets and RBC ratio of 1:1:1 with 1:1:2 on 24-hour and 30-day mortality [n=680]; one compared whole blood to blood component therapy on 24-hour blood use [n=107]; one compared a FFP to RBC ratio of 1:1 with 1:4 [n=16]. Data from two trials were pooled in a meta-analysis for 28-day mortality because the transfusion ratios achieved were similar. Results from these two trials suggest higher transfusion ratios were associated with transfusion of more FFP and platelets without evidence of significant difference with respect to mortality or morbidity. On the limited evidence available, there is insufficient basis to recommend a 1:1:1 over a 1:1:2 ratio or standard care for adult patients with critical bleeding requiring massive transfusion.

Haemotherapy algorithm for the management of trauma-induced coagulopathy: an Australian perspective.

Recent advances in the understanding of the pathophysiological processes associated with traumatic haemorrhage and trauma-induced coagulopathy have resulted in improved outcomes for seriously injured trauma patients. However, a significant number of trauma patients still die from haemorrhage. This article reviews the various transfusion strategies utilized in the management of traumatic haemorrhage and describes the major haemorrhage protocol (MHP) strategy employed by an Australian trauma centre. Few topics in trauma resuscitation incite as much debate and controversy as to what constitutes the 'ideal' MHP. There is a widespread geographical and institutional variation in clinical practice. Three strategies are commonly utilized; fixed ratio major haemorrhage protocol (FRMHP), viscoelastic haemostatic assay (VHA)-guided MHP and hybrid MHP. The majority of trauma centres utilize an FRMHP and there is high-level evidence to support the use of high blood product ratios. It can be argued that the FRMHP is too simplistic to be applied to all trauma patients and that the use of VHA-guided MHP with predominant factor concentrate transfusion can allow rapid individualized interventions. In between these two strategies is a hybrid MHP, combining early FRMHP with subsequent VHA-guided transfusion. There are advantages and disadvantages to each of the various MHP strategies and the evidence base to support one above another with any certainty is lacking at this time. One strategy cannot be considered superior to the other and the choice of MHP is dependent on interpretation of the current literature and local institutional logistical considerations. A number of exciting studies are currently underway that will certainly increase the evidence base and help inform clinical practice.

Transfusion Therapy

Exsanguination occurs rapidly after trauma (median 2 to 3 hours after admission) and is the leading cause of preventable trauma deaths. The modern treatment for traumatic hemorrhagic shock is simultaneous mechanical hemorrhage control and damage control resuscitation (DCR), which emphasizes using plasma as the primary means for volume expansion. Other core DCR principles include minimization of crystalloid, permissive hypotension, and goal-directed resuscitation. The treatment of traumatic hemorrhage is complicated by trauma-induced coagulopathy (TIC); DCR is thought to address TIC directly despite incomplete understanding of the underlying mechanisms. Recent data point to a 1:1:1 ratio of plasma and platelets to red blood cells as the optimal blood product ratio for acute traumatic hemorrhage. However, this paradigm may soon be supplanted by a transition back to whole blood. Although it is intuitive to apply these same protocols and algorithms to patients with nontraumatic hemorrhage, the scientific evidence is lacking. Key words: endotheliopathy, hemorrhage, massive transfusion, trauma-induced coagulopathy

Massive Transfusion Protocols: A Survey of Academic Medical Centers in the United States

Massive transfusion protocols (MTPs) have been adopted in many hospitals, and they may improve outcomes, as well as decrease the number of blood products transfused. However, there are no specific guidelines regarding the number and types of products that should be included in these protocols. MTPs may vary from hospital to hospital. A short, web-based survey was sent to blood bank medical directors at academic institutions to learn details about MTPs. A total of 107 survey requests were sent, and 56 were completed (52% response rate). All who responded had an MTP in place. Nearly all (n = 55, 98.2% [95% CI, 90.6%-99.7%]) base their protocol on delivery of fixed amounts and ratios of blood products, with only a minority incorporating any elements of laboratory-directed therapy. The most common target, red blood cell (RBC):plasma ratio, is 1:1 (n = 39, 69.9% [95% CI, 56.7%-80.1%] of respondents). The majority (n = 36, 64.3% [95% CI, 51.2%-75.6%]) provide 6 or more units of red blood cells in the first MTP packet. One-hundred percent of survey respondents had an MTP in place. Despite a lack of published guidelines regarding MTPs, the survey results demonstrated substantial uniformity in numbers of products and target transfusion ratios.

WHO ARE OUR ‘CODE-RED’ KIDS? – A URBAN MAJOR TRAUMA CENTRE'S EXPERIENCE OF MAJOR HAEMORRHAGE IN INJURED CHILDREN

Objectives & BackgroundMajor trauma in children, while being relatively uncommon, is still a principal cause of preventable death with severe haemorrhage being one of the main responsible reasons. ‘Major haemorrhage...

Massive Blood Transfusion in Patients with Ruptured Abdominal Aortic Aneurysm

The aim was to study blood transfusions and blood product ratios in massively transfused patients treated for ruptured abdominal aortic aneurysms (rAAAs). This was a registry based cohort study of rAAA patients repaired at three major vascular centres between 2008 and 2013. Data were collected from the Swedish Vascular Registry, hospitals medical records, and local transfusion registries. The transfusion data were analysed for the first 24h of treatment. Massive transfusion (MT) was defined as 4 or more units of red blood cell (RBC) transfused within 1h, or 10 or more RBC units within 24h. Logistic regression was used to calculate the odds ratio of 30 day mortality associated with the ratios of blood products and timing of first units of platelets (PLTs) and fresh frozen plasma (FFP) transfused. Three hundred sixty nine rAAA patients were included: 80% men; 173 endovascular aneurysm repairs (EVARs) and 196 open repairs (ORs) with median RBC transfusion 8 units (Q1-Q3, 4-14) and 14 units (Q1-Q3, 8-28), respectively. A total of 261 (71%) patients required MT. EVAR patients with MT (n=96) required less transfusion than OR patients (n=165): median RBC 10 units (Q1-Q3, 6-16.5) vs. 15 units (Q1-Q3, 9-26) (p=.002), FFP 6 units (Q1-Q3, 2-14.5) vs. 13 units (Q1-Q3, 7-24) (p<.001), and PLT 0 units (Q1-Q3, 0-2) vs. 2 units (Q1-Q3, 0-4) (p=.01). Median blood product ratios in MT patients were FFP/RBC (EVAR group 0.59 [0.33-0.86], OR group 0.84 [0.67-1.2]; p<.001], and PLT/RBC (EVAR 0 [0-0.17], OR 0.12 (0-0.18); p<.001]. In patients repaired by OR a FFP/RBC ratio close to 1 was associated with reduced 30 day mortality (p=.003). The median PLT/RBC ratio was higher during the later part of the study period (p<.001, median test), whereas there was no significant difference in median FFP/RBC ratio (p=.101, median test). The majority of rAAA patients undergoing EVAR required MT. EVAR patients treated with MT had lower FFP/RBC and PLT/RBC ratios than OR patients with MT. The mortality risk was lower with FFP/RBC ratio close to 1:1 in open repaired patients requiring MT. The 24h PLT/RBC ratio increased over the study period.

Prehospital volume resuscitation--Did evidence defeat the crystalloid dogma? An analysis of the TraumaRegister DGU® 2002-2012.

BackgroundVarious studies have shown the deleterious effect of high volume resuscitation following severe trauma promoting coagulopathy by haemodilution, acidosis and hypothermia. As the optimal resuscitation strategy during prehospital trauma care is still discussed, we raised the question if the amount and kind of fluids administered changed over the recent years. Further, if less volume was administered, fewer patients should have arrived in coagulopathic depletion in the Emergency Department resulting in less blood product transfusions.MethodsA data analysis of the 100 489 patients entered into the TraumaRegister DGU® (TR-DGU) between 2002 and 2012 was performed of which a total of 23512 patients (23.3 %) matched the inclusion criteria. Volume and type of fluids administered as well as outcome parameter were analysed.ResultsBetween 2002 and 2012, the amount of volume administered during prehospital trauma care decreased from 1790 ml in 2002 to 1039 ml in 2012. At the same time higher haemoglobin mean values, higher Quick’s mean values and reduced mean aPTT can be observed. Simultaneously, more patients received catecholamines (2002: 9.2 to 2012: 13.0 %). Interestingly, the amount of volume administered decreased steadily regardless of the presence of shock. Fewer patients were in the need of blood products and the number of massive transfusions (≥10 pRBC) more than halved.DiscussionThe changes in volume therapy might have reduced haemodilution potentially resulting in an increase of the Hb value. During the period observed transfusion strategies have become more restrictiveand ratio based; the percentage of patients receiving MT halved as blood products may imply negative secondary effects. Furthermore, preventing administration of high blood product ratios result in less impairment of coagulation factors and inhibitors and an therfore improved coagulation.ConclusionThe volume administered in severely injured patients decreased considerably during the last decade possibly supporting beneficial effects such as minimizing the risk of coagulopathy and avoiding potential harmful effects caused by blood product transfusions. Despite outstanding questions in trauma resuscitation, principle evidence merges quickly into clinical practice and algorithms.

Massive transfusion in critical haemorrhage following trauma: Aren't we missing something?

We read with interest the recent review by Olaussen et al., presenting 36 models for prediction of critical haemorrhage following trauma. The authors present the different models, their respective variables and their performance. They also discuss the utility of the individual variables. As mentioned in the publication, early diagnosis of haemorrhagic shock is a key step in improving outcomes after severe trauma. Critical bleedings indeed require aggressive treatments and need them to be applied as early as possible. Moreover, any unilateral approach would cause harm as critical bleedings require integrative care associating a mechanical (surgical or endovascular) strategy to stop the bleeding with adequate haemostatic resuscitation. Damage control resuscitation (DCR) associates damage control surgery (DCS), massive transfusion (MT) with the optimal 1/1/1 ratio of blood products, permissive hypotension and careful attention for identification and correction of the early acute coagulopathy of trauma (EACT). Adequate and early selection of trauma patients in need for DCR is pivotal to prevent wasting time as well as unnecessary activation of the technical and human resources needed for DCR. The presented models all have been developed by retrospective identification of individual parameters independently associated with MT. Massive transfusion is commonly defined as the transfusion of more than 10 units of red blood cells (RBC) within the first 24 hours of care. This definition is problematic since it excludes trauma patients presenting to hospital with active bleeding and a need for an emergent surgical control of the bleeding. Thanks to a highly effective DCR, some of those patients do not need a large number of RBC transfusions. Moreover, severe blunt trauma patients can suffer from an EACT and are in need of a specific haemostatic resuscitation (associating treatments such as tranexamic acid, plasma, platelets or fibrinogen concentrate) and not necessarily in need of massive RBC transfusion. Defining critical haemorrhage with MT therefore does not properly consider the other crucial components of DCR (DCS and correction of EACT) which are as important as RBC transfusion. Shouldn’t we both in the clinical setting and in clinical research change our perspective, going from a massive transfusion approach to a critical haemorrhage approach? Other scoring systems have been developed with a different endpoint. The coagulopathy of severe trauma (COAST) score, developed by the same team of the present review, aims to identify trauma patients suffering from EACT. The trauma induced coagulopathy clinical score (TICCS) aims to identify trauma patients associating EACT, the need for blood products transfusion and the need for emergent surgery. There is no doubt that the presented models are all very useful in clinical practice as they bring an objective tool for prediction of critical haemorrhage. We would like to know the authors’ opinion about choosingMT as the focused outcome variable and if it is the answer to critical haemorrhage after trauma.