In massive blood transfusion (>10 units pRBC in 24 hours), the recommended ratio of packed red blood cells : fresh frozen plasma : platelets for damage control resuscitation is:

• A 6 : 1 : 1 (RBC heavy protocol)
• B 4 : 2 : 1 (standard crystalloid-first protocol)
• C 1 : 0 : 0 (RBC only until coagulation studies return)
• D 1 : 1 : 1 (balanced haemostatic resuscitation) ✓

Explanation

The PROPPR trial (2015) established that a 1:1:1 ratio of pRBC:FFP:platelets improves haemostasis and reduces 24-hour mortality compared to a 1:1:2 ratio in trauma-associated massive haemorrhage. This balanced haemostatic resuscitation mimics reconstituted whole blood and prevents dilutional coagulopathy — the main reason for mortality in massive transfusion. The older practice of 6:1 pRBC:FFP (RBC-heavy) leads to dilutional coagulopathy. Crystalloid-first approaches worsen outcomes in haemorrhagic shock.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.