Update on the massive transfusion guidelines on hemorrhagic shock: After the wars

Over the past decade, crystalloid-and red blood cell-dominated massive resuscitation practices have largely been replaced with high-ratio transfusion of plasma, pla-telets, and red blood cells (RBCs) in massively bleeding trauma patients. Literature from military and civilian experiences with massive transfusion (MT) was reviewed, beginning with military transfusion practices at the onset of the wars in Afghanistan and Iraq and continuing through to present day. Early and balanced resuscitation (1:1:1 ratio of plasma, platelets, and RBCs) is superior to crystalloid-or red blood cell-driven resuscitation. Military research from Afghanistan and Iraq stimulated civilian investigations into ratio-based MT. 1:1:1 resuscitation carries the most benefit for massively bleeding trauma patients. Thrombelastogra-phy-guided MT can be used to supplement empiric 1:1:1 therapy in order to detect and address specific coagu-lopathies. Future directions in MT research presently include resuscitation with fresh whole blood and pre-hos-pital plasma-based resuscitation.