Management of transfusion in traumatic hemorrhagic shock

PURPOSE OF REVIEW: Traumatic hemorrhagic shock remains the leading preventable cause of early trauma death, with most deaths occurring within the first 24 h. This review summarizes recent advances in prediction tools, transfusion protocols, blood products and monitoring strategies for transfusion management. RECENT FINDINGS: Transfusion management relies on early activation of major hemorrhage protocols and rapid delivery of balanced blood components to limit coagulopathy and restore oxygen delivery. Prehospital transfusion appears most beneficial in the most severely injured patients, particularly with prolonged transport times, though its mortality benefit varies across trauma systems and patient phenotypes. Low-titer group O whole blood simplifies logistics and may improve early hemostasis, but randomized trials have not shown a clear survival advantage over component therapy. Viscoelastic testing complements empirical algorithms by enabling faster, targeted correction of fibrinogen and factor deficiency. Emerging data also highlight the prognostic impact of ionized calcium disturbances and the potential of machine-learning models for early risk stratification. SUMMARY: Current evidence supports a time-critical, system-based approach in which standardized transfusion bundles are triggered early and refined using viscoelastic guidance. Future work should prioritize prospective validation of decision-support tools, phenotype-specific strategies, clarification of whole blood's role, and rigorous evaluation of emerging blood products.