The transfusion approach to massive
hemorrhage has continually evolved since it began in the early 1900s. It started with fresh whole blood and currently consists of virtually exclusive use of component and
crystalloid therapy. Recent US military experience has reinvigorated the debate on what the most optimal transfusion strategy is for patients with traumatic
hemorrhagic shock. In this review we discuss recently described mechanisms that contribute to traumatic coagulopathy, which include increased anti-
coagulation factors and hyperfibrinolysis. We also describe the concept of damage control
resuscitation (DCR), an early and aggressive prevention and treatment of
hemorrhagic shock for patients with severe life-threatening traumatic
injuries. The central tenants of DCR include hypotensive
resuscitation, rapid surgical control, prevention and treatment of
acidosis,
hypothermia, and
hypocalcemia, avoidance of
hemodilution, and
hemostatic resuscitation with transfusion of red blood cells, plasma, and platelets in a 1:1:1 unit ratio and the appropriate use of
coagulation factors such as
rFVIIa and
fibrinogen-containing products (
fibrinogen concentrates, cryoprecipitate). Fresh whole blood is also part of DCR in locations where it is available. Additional concepts to DCR since its original description that can be considered are the preferential use of "fresh" RBCs, and when available thromboelastography to direct blood product and
hemostatic adjunct (anti-fibrinolytics and
coagulation factor) administration. Lastly we discuss the importance of an established massive transfusion protocol to rapidly employ DCR and
hemostatic resuscitation principles. While the majority of recent
trauma transfusion papers are supportive of these general concepts, there is no Level 1 or 2 data available. Taken together, the preponderance of data suggests that these concepts may significantly decrease mortality in massively transfused
trauma patients.