In the damage control resuscitation (DCR) paradigm for hemorrhagic shock, what is the recommended ratio of packed red blood cells : fresh frozen plasma : platelets in massive transfusion protocol?

• A 10:1:1 (predominantly RBC)
• B 2:1:1
• C RBC only until hemostasis achieved, then FFP
• D 1:1:1 (balanced component therapy) ✓

Explanation

The PROPPR trial (NEJM 2015) demonstrated that a 1:1:1 ratio of pRBC:FFP:platelets reduces 24-hour and 30-day mortality and achieves faster hemostasis compared with 1:1:2 ratios in trauma patients requiring massive transfusion. This balanced resuscitation approach ('whole blood equivalent') mirrors the composition of whole blood and prevents dilutional coagulopathy. High-volume RBC-only resuscitation worsens acidosis, hypothermia, and coagulopathy — the 'lethal triad.' DCR also includes permissive hypotension (target MAP 50–65 mmHg), tranexamic acid (CRASH-2 protocol within 3 hours), and avoidance of crystalloid excess.

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

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