In major hemorrhage protocols, give no fewer than four units of fresh frozen plasma and one unit of platelets for every eight units of red blood…
Annales francaises d'anesthesie et de reanimation 2013
Massive transfusion protocols key in trauma coagulopathy
Early activation of massive transfusion protocols with high ratios (RBC:FFP:Platelets) is key in trauma-induced coagulopathy for hemostatic…
IN PRACTICE
Massive transfusion: Use 1:1:1 to 1:1:2 ratios
Other · The American journal of emergency
Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of plasma, platelets, and red blood cells.
Massive transfusion protocol in adult trauma population, The American journal of emergency medicine 2020 · PMID 33071074
IN PRACTICE
Confirm tube position bronchoscopically
Other · England)
The provided text is an abstract list from a conference, not a paper detailing massive transfusion protocols or hemorrhagic shock management. Therefore, I cannot extract a specific, actionable teaching point related to that topic from this source.
36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016, Critical care (London, England) 2016 · PMID 27885969
In major hemorrhage protocols, give no fewer than four units of fresh frozen plasma and one unit of platelets for every eight units of red blood cells.
Patient blood management guideline for adults with critical bleeding, The Medical journal of Australia 2024 · PMID 38282333
IN PRACTICE
Massive transfusion protocols key in trauma coagulopathy
Other · Annales francaises d'anesthesie et
Early activation of massive transfusion protocols with high ratios (RBC:FFP:Platelets) is key in trauma-induced coagulopathy for hemostatic resuscitation.
Trauma-induced coagulopathy, Annales francaises d'anesthesie et de reanimation 2013 · PMID 23916515
IN THE ROOM
What this changes about the next case
Colour is the strength of the evidence behind each step, not the urgency.
1
1
Current massive transfusion protocols should utilize between 1:1:1 and 1:1:2 ratios of plasma, platelets, and red blood cells.
2
2
The provided text is an abstract list from a conference, not a paper detailing massive transfusion protocols or hemorrhagic shock management. Therefore, I cannot extract a specific, actionable teaching point related to that topic from this source.
3
3
In major hemorrhage protocols, give no fewer than four units of fresh frozen plasma and one unit of platelets for every eight units of red blood cells.
4
4
Early activation of massive transfusion protocols with high ratios (RBC:FFP:Platelets) is key in trauma-induced coagulopathy for hemostatic resuscitation.
The oral-boards stem on the next slide puts these into one scenario.
Massive transfusion protocols key in trauma coagulopathy
Annales francaises d'anesthesie et de reanimation 2013
Activate massive transfusion early using RBC:FFP:Platelet ratios of 1:1:1 to 1:1:2 for optimal hemostasis in hemorrhagic shock.
Questions I'll ask you in the room
What is the most common cause of death in patients receiving massive transfusions?
How does citrate toxicity manifest and what factors increase its risk?
What laboratory values are most useful for guiding transfusion therapy in a patient with massive hemorrhage?
Besides packed red blood cells, what other blood products should be considered early in massive transfusion protocols?
Oral boards stem
A 24-year-old arrives after a motorcycle collision with a positive FAST, systolic pressure of 70, and a hemoglobin of 6.2 after two litres of crystalloid.
Board questions
1. In PROPPR, roughly how many units of plasma and platelets did the 1:1:1 group receive in the first 24 hours compared with 1:1:2, and did red cell use differ?
Show answer
The 1:1:1 group received more plasma (median 7 units versus 5) and considerably more platelets (12 units versus 6), while red cell volumes were similar at about 9 units in both groups. So the ratio strategy changes what comes out of the cooler alongside the red cells, not how much red cell is given.
The intervention is plasma and platelets, delivered early. Knowing the actual unit counts makes the logistics of activating the protocol concrete.
2. In the PROPPR trial comparing 1:1:1 with 1:1:2 plasma:platelet:red cell ratios in severe trauma, which endpoints differed significantly between the groups?
Death from exsanguination at 24 hours and achievement of haemostasis
All-cause mortality at both 24 hours and 30 days
Acute respiratory distress syndrome and multiple organ failure
No endpoint differed significantly
Show answer
A. Death from exsanguination at 24 hours and achievement of haemostasis
Neither mortality endpoint reached significance (12.7% vs 17.0% at 24h; 22.4% vs 26.1% at 30d). Exsanguination death fell from 14.6% to 9.2% and haemostasis rose from 78% to 86%. The trial is usually quoted as showing 1:1:1 works — what it showed is narrower and more interesting than that.
3. A colleague argues PROPPR proves a 1:1:1 ratio saves lives in major trauma haemorrhage. What is the precise problem with that claim, and what can you legitimately say the trial supports?
Show answer
PROPPR's primary outcomes were 24-hour and 30-day all-cause mortality, and neither reached statistical significance — 12.7% versus 17.0%, and 22.4% versus 26.1%. So it did not demonstrate a mortality benefit. What it did show, in prespecified ancillary outcomes, was less death from exsanguination (9.2% vs 14.6%) and more patients achieving haemostasis (86% vs 78%), without an increase in any of 23 prespecified complications. The defensible statement is that 1:1:1 increased the proportion of patients achieving haemostasis and reduced deaths from exsanguination, at no measured safety cost.
Ancillary outcomes can be real and useful without converting a negative primary outcome into a positive trial. Say what the trial measured.
The bottom lineActivate massive transfusion early using RBC:FFP:Platelet ratios of 1:1:1 to 1:1:2 for optimal hemostasis in hemorrhagic shock.
Sources
[1] Massive transfusion protocol in adult trauma population, The American journal of emergency medicine 2020 · PMID 33071074 open
[2] 36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016, Critical care (London, England) 2016 · PMID 27885969 open
[3] Patient blood management guideline for adults with critical bleeding, The Medical journal of Australia 2024 · PMID 38282333 open
[4] Trauma-induced coagulopathy, Annales francaises d'anesthesie et de reanimation 2013 · PMID 23916515 open