Hemorrhage and coagulopathy in the critically ill.

Bleeding is the second leading cause of death after trauma. Initial care of the patient with hemorrhage focuses on restoring circulating blood volume and reversing coagulopathy. Trauma and injury can initiate the coagulation cascade. Patients with massive bleeding should be resuscitated with goal-directed therapy. Hemostatic resuscitation in conjunction with ratio-based transfusion and massive transfusion protocols should be utilized while awaiting hemorrhage control. The military initiated massive transfusion protocols in the battlefield. We discuss the coagulation cascade, recent recommendations of goal-directed therapy, massive transfusion protocols, fixed ratios, and the future of transfusion medicine.