Wehrmedizinische Monatsschrift

Transfusion Medicine and Hemotherapy

Massive Transfusion in a Military Setting

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Massive Transfusion in a Military Setting

Sascha Hashemian^a, Jan Ammann^a

^aDepartment AINS, Bundeswehrkrankenhaus Ulm

Summary

Massive transfusion is a crucial stabilizing measure for severely bleeding trauma patients, characterized by rapid and high blood product use. To manage this effectively, so-called massive transfusion protocols are widely adopted. These hospital-specific standard operating procedures (SOPs) enhance medical care and logistics while reducing the workload on treatment teams. The benefits also offer opportunities in military settings. This article discusses the unique aspects and challenges of massive transfusion in a military context, as well as the advantages of implementing massive transfusion protocols.

Keywords: massive transfusion; massive transfusion protocol (MTP); transfusion in a military context; blood product logistics

Introduction

Hemorrhage is the leading potentially survivable cause of death on the battlefield. Therefore, military medical training has traditionally emphasized hemostasis. When a wounded person with hemorrhage reaches a treatment facility of various levels, one of the main goals is damage control resuscitation (see the article “Damage Control Resuscitation” in this issue). It is now understood that aggressive fluid therapy with crystalloids should be avoided due to its dilution effect on coagulation factors, the risk of developing acidosis, lowering core body temperature, and possibly worsening active bleeding by increasing arterial and venous pressure [4]. Instead, blood products should be administered promptly to bleeding, hemodynamically unstable patients, and in cases of severe bleeding, a massive transfusion protocol (MTP) should be employed. This article aims to describe the specific features of massive transfusion and the options for implementing an MTP in a military setting.

Fig. 1: Illustration of a possible indication algorithm for a massive transfusion protocol

Massive Transfusion Protocol

A massive transfusion is defined as the transfusion of 10 or more units of red blood cell concentrates (RBCs) within 24 hours or 4 or more units within 6 hours. A massive transfusion protocol (MTP) is a standardized, hospital-specific process that coordinates the rapid delivery of various blood products. MTPs are common in civilian trauma care, considered standard practice, and recommended in various guidelines [2]. The purpose of an MTP is to replace blood loss with blood components that match the physiological composition of blood, as well as to provide coagulation therapy.

Suitable criteria for initiating an MTP include injuries with expected significant blood loss (half of the circulating blood volume or ongoing bleeding), lactate levels ≥ 5 mmol/L, systolic blood pressure ≤ 90 mmHg, heart rate ≥ 105/min, and organ dysfunction. Figure 1 schematically illustrates a possible indication algorithm. An MTP initially sets the basic conditions necessary for hemostasis: normothermia, pH > 7.2, and ionized Ca²⁺ > 0.9 mmol/L. These are derived from the “lethal triad” of trauma – hypothermia, acidosis, and coagulopathy – recently supplemented by hypocalcemia as the “lethal diamond” [6].

The MTP process is usually divided into phases. The initial treatment phase typically includes transfusing 4 units of red blood cells (RBCs), 4 units of fresh frozen plasma (FFP), and 1 unit of platelet concentrate (PC), along with providing additional coagulation products such as fibrinogen, tranexamic acid, and calcium. Early steps like cross-matching extra RBCs, conducting a standard trauma lab, and performing point-of-care (POC) diagnostics should be completed. POC diagnostics encompass venous or arterial blood gas analysis and viscoelastic testing methods like thromboelastography.

In subsequent MTP blocks, additional blood products are transfused in the same ratio (4:4:1), with standardized administration of calcium and fibrinogen based on POC diagnostics. During an MTP, prothrombin complex concentrate (PCC), Factor XIII, Factor VII, and desmopressin may also be given. In patients on anticoagulation, these can be countered with appropriate antidotes or coagulation preparations. Hospital-specific differences often lead to deviations from the standard protocol due to logistical challenges in providing PCs, which can delay the initial administration of a PC until the second or third block, ensuring the 4:4:1 ratio is restored.

Fig. 2: Schematic representation of two MTPs for packaged blood products (left) and whole blood (right) * Adjustment according to clinic and laboratory chemistry necessary

MTPs enable faster, more organized delivery of blood products through logistical planning and enhanced interdisciplinary communication [7]. This also shortens the delay before the first transfusion, directly improving trauma patient care. A meta-analysis showed that implementing an MTP results in a statistically and clinically meaningful reduction in overall mortality among trauma patients [3]. Contrary to some beliefs, MTPs do not increase blood product use; instead, they decrease it [8].

MTP in the Military Context

The benefits demonstrate that MTPs are essential in civilian trauma treatment and can also help injured personnel in military settings. Specifically, structured transfusion protocols and early stabilization of the wounded can reduce treatment times, allowing for quicker surgical interventions.

Due to tactical medical principles and logistical challenges, an MTP is only appropriate for treatment levels of Role 2 and above. In the military setting, a limitation is the reduced availability of blood products. During mass casualty situations, a massive transfusion for a single wounded person may consume so many resources that it significantly affects the care of other injured individuals. In such events, the use of blood products and an MTP must be carefully evaluated to prevent prioritizing one patient at the expense of others. Additionally, storing and transporting RBCs, FFP, and PCs pose challenges because of their different temperature requirements, making whole blood a more suitable option.

Massive Transfusion of Whole Blood

The transfusion of whole blood is an essential aspect of military transfusion medicine. In addition to its well-known benefits, its use becomes particularly important in the context of massive transfusions and MTPs. Physiologically, transfusing whole blood more accurately reflects the blood components that need to be replaced due to blood loss. Whole blood is superior to various concentrates regarding coagulation and coagulation factor activity [9].

The additive solution in whole blood varies in type and amount from those in RBCs, FFP, and PCs. Whole blood contains about 70 ml of a citrate-containing additive solution. RBCs have 100–120 ml of citrate, PCs 100–150 ml, and FFP no volume but also citrate [1][5]. A whole blood equivalent of various concentrates in a 1:1:0.25 ratio contains twice the amount of additive solution with a higher citrate level. This leads to more dilution and increased calcium chelation because of the higher citrate concentration during massive transfusion with concentrates [9].

Another advantage is simpler storage requirements. While RBCs must be refrigerated, FFP frozen, and PCs stored at room temperature with constant agitation, whole blood only needs refrigeration. This lessens the technical and logistical demands on a treatment facility and its supplies. Limitations of using whole blood include its relatively short shelf life compared to plasma products, such as FFP or lyophilized plasma [10].

In practice, the medical treatment team benefits from the reduced number of transfusion bags needed when using whole blood. Using whole blood improves compliance and speeds up the MTP process. Figure 2 illustrates the schematic sequence of an MTP with packaged blood products versus whole blood.

Conclusion

A massive transfusion in a military setting, under conditions of limited personnel and resources and in highly dynamic, hard-to-coordinate situations, presents a significant challenge. Massive transfusion protocols have proved effective in civilian trauma care and could enhance medical treatment and support military medical personnel, especially by using whole blood.

Key Points

Massive transfusions pose a particular challenge in the military context.
MTPs are a proven standard in civilian emergency and acute medicine.
MTPs provide security in massive transfusions and thus relieve medical personnel.
The military context can benefit from establishing an MTP.
The use of whole blood simplifies the implementation of massive transfusions and MTPs.

References

Beeck H, Becker T, Kiessig ST, et al. The influence of citrate concentration on the quality of plasma obtained by automated plasmapheresis: a prospective study. Transfusion. 1999;39(11-12):1266-1270. mehr lesen
Bieler D, Düsing H, Flohé S, et al. Polytrauma/Schwerverletzten-Behandlung S3-Leitlinie (Langfassung) [Internet]. AWMF 2022 [last access March 15, 2026];available from: https://register.awmf.org/assets/guidelines/187-023l_S3_Polytrauma-Schwerverletzten-Behandlung_2023-06.pdf mehr lesen
Consunji R, Elseed A, El-Menyar A, et al. The effect of massive transfusion protocol implementation on the survival of trauma patients: a systematic review and meta-analysis. Blood Transfus. 2020;18(6):434-445. mehr lesen
Dhillon NK, Kwon J, Coimbra R. Fluid resuscitation in trauma: What you need to know. J Trauma Acute Care Surg. 2025;98(1):20-29. mehr lesen
Gulliksson H. Platelet storage media. Vox Sang. 2014;107(3):205-212. mehr lesen
Lier H, Hossfeld B. Massive transfusion in trauma. Curr Opin Anaesthesiol. 2024;37(2):117-124. mehr lesen
Lim G, Harper-Kirksey K, Parekh R, Manini AF. Efficacy of a massive transfusion protocol for hemorrhagic trauma resuscitation. Am J Emerg Med. 2018;36(7):1178-1181. mehr lesen
O'Keeffe T, Refaai M, Tchorz K, Forestner JE, Sarode R. A massive transfusion protocol to decrease blood component use and costs. Arch Surg. 2008;143(7):686-690; discussion 90-1. mehr lesen
Ponschab M, Schöchl H, Gabriel C, et al. Haemostatic profile of reconstituted blood in a proposed 1:1:1 ratio of packed red blood cells, platelet concentrate and four different plasma preparations. Anaesthesia. 2015;70(5):528-536. mehr lesen
Sauer D, Meyer J. Versorgung mit Blut und Blutprodukten in militärischen Einsatzgebieten. Transfusionsmedizin. 2025;15(01):16-27. mehr lesen

Manuscript Data

Citation

Hashemian S, Ammann A. Massive transfusion in a military setting. WMM 2026;70(5E):7.

DOI: https://doi.org/10.48701/opus4-870

For the Authors

Captain (MC) Dr. Sascha Hashemian

Department of Anesthesiology, Intensive Care, Emergency Medicine, and Pain Therapy (AINS)

Bundeswehr Hospital Ulm

Oberer Eselsberg 40, D-89081 Ulm

E-Mail: saschahashemian@bundeswehr.org

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