Practical management of major blood loss.

The pathophysiology of bleeding, regardless of cause, is complex and ill understood. For traumatic or sudden unexpected haemorrhage, the use of transfusion packs with red cells, fresh frozen plasma, cryoprecipitate and platelets being given in ratios of between 1:1 and 1:3 seems reasonable. This removes the requirement for 'wait and see tests' and should be part of an overall resuscitation and stabilisation plan that may improve outcome following sudden haemorrhage. The replacement of fresh frozen plasma and cryoprecipitate with low-volume, targeted concentrates is attractive. There is increasing evidence for the efficacy and safety of fibrinogen concentrates as a single agent. The combination of fibrinogen and prothrombin complex concentrates could be powerful and has the possibility to the management of bleeding and improve outcome in patients but, as yet, remains unproven.