Massive Transfusion, Blood Products & Tranexamic Acid

Also known as Massive transfusion · Massive haemorrhage protocol · Blood products in resuscitation · Tranexamic acid · TXA · PROPPR trial · CRASH-2 · TRALI · TACO · Damage control resuscitation · Permissive hypotension · Haemostatic resuscitation · Damage control surgery · Viscoelastic testing · TEG · ROTEM · WOMAN trial · HALT-IT · Lethal triad

Massive transfusion in resuscitation turns on two evidence-based questions: the component ratio (PROPPR — 1:1:1 vs 1:1:2 RBC:plasma:platelets) and tranexamic acid (CRASH-2 — mortality benefit, but only within 3 hours of injury; WOMAN in postpartum haemorrhage, HALT-IT negative in GI bleed, TICH-2 in intracerebral haemorrhage). Damage control resuscitation (permissive hypotension, haemostatic 1:1:1 resuscitation, damage control surgery), viscoelastic (TEG/ROTEM)-guided component therapy, fibrinogen replacement above 1.5-2.0 g/L, calcium replacement (citrate chelation), the lethal triad of hypothermia-acidosis-coagulopathy, and awareness of transfusion reactions (TRALI, TACO, acute haemolysis) are central.

high26 referencesUpdated 3 Sept 202629 min readSource-verified · Sept 2026

Checked against its sources on 3 Sept 2026

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8 MCQs

The one-line answer

Massive transfusion supports the bleeding patient while bleeding is controlled. Two evidence-based decisions dominate: the component ratio (PROPPR — with 1:1:1 vs 1:1:2 plasma:platelets:RBC, deaths from exsanguination within 24 hours were significantly fewer and more patients achieved haemostasis; 24-hour and 30-day all-cause mortality did not differ significantly) and tranexamic acid (CRASH-2 — 1 g IV over 10 min then 1 g over 8 h reduced all-cause and bleeding death; the exploratory timing analysis shows benefit only within 3 hours of injury — after 3 hours bleeding death increased). Activate the massive haemorrhage protocol early, minimise crystalloid, monitor and replace ionised calcium (citrate chelation), replace fibrinogen early (the first factor to fall in traumatic haemorrhage), and prevent the lethal triad. TXA does NOT reduce death in gastrointestinal bleeding (HALT-IT enrolled upper or lower GI bleeding) or improve 90-day functional outcome after spontaneous intracerebral haemorrhage (TICH-2).^[1]^[2]^[3]^[7]^[8]^[13]^[15]

Meet the patient

A 28-year-old man arrives by helicopter after a high-speed motorcycle crash with a severe pelvic fracture and an open femur fracture. BP 70/40, HR 135, lactate 7. The massive haemorrhage protocol is activated.^[1]

Two decisions in the next five minutes will determine whether he survives: the ratio of blood products you hang on the rapid infuser (PROPPR says 1:1:1) and whether you give TXA within the 3-hour window (the CRASH-2 timing analysis says yes, now). Everything else — calcium, warming, fibrinogen, the surgeon — runs in parallel. Transfusion buys time; only bleeding control saves the life.^[1]^[2]^[3]

References26Show

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