The Advanced Trauma Life Support (ATLS) course of the American College of Surgeons suggests starting two large-bore IVs in patients who are significantly injured or appear to be going into shock and, if they are hypotensive, giving 2 L of crystalloid solution.11 If such patients remain in shock, recover initially, but subsequently go back into shock, or have active ongoing bleeding of greater than 100 mL/ minute, then RBCs should be given. These guidelines were based on the recognition that prolonged shock frequently led to renal failure that could be prevented by volume resuscitation and that many injured patients, who suffered decreases in their blood pressure, did not need blood at all.
Other groups have added guidelines for the administration of platelets and plasma. In 1994, the College of American Pathologists (CAP) advocated transfusion of plasma to keep the international normalized ratio (INR) below 1.5 and of platelets to maintain counts higher than 50 x 109/L in actively bleeding patients.12 They suggested that such transfusions should be triggered by measured laboratory values. In 1996, the American Society of Anesthesiologists (ASA) also recommended administration of plasma to keep the INR below 1.5 and platelets to maintain counts higher than 50 x 109/L in hemodynamically normal but actively bleeding patients, and suggested that raising platelet counts to 100 x 109/L may be useful in multiply or massively injured patients.13 They also emphasized the importance of the clinical assessment of coagulopathy and its rapid treatment in the face of ongoing bleeding. In 2007, the European Task Force for Advanced Bleeding Care in Trauma (ABC-T) repeated these recommendations and again noted that the evidence supporting them comes exclusively from observational studies and case series.14
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