Modern Massive Transfusion Protocols in Trauma: Prediction, Delivery, and Hemorrhage Control

Abstract Purpose of Review Traumatic hemorrhage remains a leading cause of potentially preventable death, particularly within the first 24 h after injury. Trauma resuscitation transitioned from whole blood use to crystalloid-dominant strategies with component therapy, but has pivoted back to balanced transfusion practices with whole blood and component products. Despite recognition that time to resuscitation is paramount, and despite widespread adoption substantial variability remains in massive transfusion protocol (MTP) activation criteria and transfusion practices. This article reviews the current literature on MTP prediction, activation, delivery, and integration with definitive hemorrhage control. Recent Findings Multiple physiologic, biochemical, and imaging-based predictors have been evaluated; however, many improve risk stratification but demonstrate only moderate predictive performance. Prehospital activation is likely to be superior to highly specific but later activation criteria. Recent machine-learning models have shown promising predictive accuracy and may facilitate earlier MTP activation, but are still in the early exploratory phase. Once activated, the MTP cooler should contain a balanced ratio of component therapy, or where possible, whole blood, and “door-to-cooler time” should be evaluated as a quality improvement metric. Consideration should be given to integration of direct-to-operating room (DTOR) pathways. Summary Traumatically injured patients often die of acute blood loss. A standardized MTP including prehospital activation, balanced and timely product delivery, and facilitation of hemorrhage control has significant potential to improve how trauma systems treat these patients.