Protective Blood Cells Around Child

Massive Transfusion in Pediatric Trauma: Why the 1:1 Ratio Could Save Lives

Theo Raines in Health & Wellness August 2025 • 5 min read.

"New research sheds light on the optimal blood component ratio for massive transfusions in children, potentially improving survival rates in severe trauma cases."

Trauma is the leading cause of death in children. While less frequent than in adults, traumatic injuries often lead to fatalities due to hemorrhage. Rapid intervention is essential, especially in light of the 'lethal triad'—coagulopathy, hypothermia, and acidosis—which complicates hemorrhage in injured children. Quickly addressing these issues improves outcomes, but determining the best strategy to manage coagulopathy from traumatic blood loss remains a challenge.

Transfusing blood components aims to use resources wisely. However, giving unbalanced blood products can worsen coagulopathy, especially when many transfusions are needed quickly. Massive Transfusion Protocols (MTPs) allow blood products to be given rapidly in fixed ratios. There's a lot of research on the best MTP makeup for adults. These studies try to reduce coagulopathy and death. The suggested ratios vary, with some centers using a 1:1:1 ratio of packed red blood cells (pRBC), fresh frozen plasma (FFP), and platelets (PLT), similar to combat support hospitals. Others use a 10:4:2 ratio, which has been successful in civilian trauma centers. While the ideal ratio for adults is still debated, evidence shows that using MTPs improves results for adults with severe trauma.

In situations involving significant blood loss, replacing intravascular volume is crucial to sustain organ function. While both crystalloid and colloid fluids can quickly expand volume, excessive use of intravenous fluids diminishes the blood's oxygen-carrying capacity and clotting ability through dilution, among other potential mechanisms. Shock and coagulopathy are known contributors to mortality and morbidity in trauma, independent of the patient's injury severity. The current approach to trauma care, known as 'damage control resuscitation,' involves component administration to minimize coagulopathy while maximizing oxygen-carrying capacity. However, the optimal blood component ratio for children remains unknown.

The 1:1 pRBC:FFP Ratio: A Game-Changer for Pediatric Trauma?

A multi-center retrospective study from the ATOMAC (Arizona, Texas, Oklahoma, Memphis, Arkansas Consortium) Level I Pediatric Trauma Centers (PTC) provides crucial insights into massive transfusions in pediatric trauma patients. The study reviewed data from January 1, 2007, to December 31, 2013, including children up to 18 years old who received at least two units of pRBCs, 20ml/kg of pRBCs, or underwent an institutional massive transfusion protocol within 24 hours of injury. The analysis focused on blood products administered within this initial 24-hour window, excluding patients requiring extra-corporeal life support.

The study revealed a significant association between the pRBC:FFP ratio and survival rates:

Highest Survival: Children receiving a 1:1 pRBC:FFP ratio had the highest survival rates.
Increased Mortality Risk: Ratios of 2:1 or ≥3:1 were linked to a significantly increased risk of death.
Age Independence: The 1:1 ratio's benefit remained consistent across different age groups, addressing concerns that younger children might need different ratios due to their unique coagulation profiles.

These findings support the idea of using a higher blood component utilization ratio for pediatric trauma patients needing massive transfusions. This challenges the traditional approach and offers a more effective strategy for saving lives.

The Future of Pediatric Trauma Care: Implementing Optimal Transfusion Protocols

This research underscores the need for standardized massive transfusion protocols (MTPs) that prioritize a 1:1 pRBC:FFP ratio in pediatric trauma settings. Implementing such protocols can improve product availability, speed up transfusions, reduce reliance on lab results, and simplify decision-making during critical situations.

The study also advocates for a reevaluation of the definition of massive transfusion in children. The traditional threshold of >40ml/kg of blood products within 24 hours may be too high, delaying the implementation of potentially life-saving MTPs. A lower threshold could encourage earlier intervention and better outcomes.

While these findings are promising, prospective randomized multi-center trials are needed to confirm these results and refine the definition of massive transfusion in pediatrics. Further research will help to optimize blood component ratios and improve survival rates for severely injured children, ultimately transforming pediatric trauma care.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.1016/j.jpedsurg.2018.10.040, Alternate LINK

Title: Massive Transfusion In Pediatric Trauma: An Atomac Perspective

Subject: General Medicine

Journal: Journal of Pediatric Surgery

Publisher: Elsevier BV

Authors: Daniel K. Noland, Nadja Apelt, Cynthia Greenwell, Jefferson Tweed, David M. Notrica, Nilda M. Garcia, R. Todd Maxson, James W. Eubanks, Adam C. Alder

Published: 2019-02-01

Everything You Need To Know

What does a 1:1 pRBC:FFP ratio mean in the context of massive transfusions for pediatric trauma patients, and why is it considered important?

In pediatric trauma, a 1:1 pRBC:FFP ratio means that for every one unit of packed red blood cells (pRBC) transfused, one unit of fresh frozen plasma (FFP) is also transfused. Research indicates this balanced approach can improve survival rates in severely injured children by addressing coagulopathy and optimizing oxygen-carrying capacity. This is especially vital given that trauma is a leading cause of death in children and rapid intervention is essential. Other ratios such as 2:1 or greater have been shown to significantly increase the risk of death.

What is the 'lethal triad' in the context of pediatric trauma, and why is it so critical to address it during massive transfusions?

The 'lethal triad' refers to the combination of coagulopathy, hypothermia, and acidosis. This dangerous combination often complicates hemorrhage in injured children, making it more difficult to manage bleeding and increasing the risk of death. Addressing each element of the lethal triad is crucial for improving outcomes in pediatric trauma cases, especially when massive transfusions are needed. Addressing the lethal triad improves outcomes by preventing further complications from blood loss.

What is 'damage control resuscitation' in pediatric trauma, and how does the 1:1 pRBC:FFP ratio fit into this approach?

Damage control resuscitation in pediatric trauma involves administering blood components to minimize coagulopathy while maximizing oxygen-carrying capacity. The goal is to quickly restore intravascular volume and address the 'lethal triad'—coagulopathy, hypothermia, and acidosis. The ideal approach uses a 1:1 pRBC:FFP ratio, as it has shown to significantly improve survival rates. Other methods like excessive crystalloid or colloid fluids can dilute the blood's oxygen-carrying capacity and clotting ability, which negatively impacts outcomes.

What are Massive Transfusion Protocols (MTPs), and how can implementing standardized MTPs with a 1:1 pRBC:FFP ratio improve outcomes in pediatric trauma?

Massive Transfusion Protocols (MTPs) are standardized guidelines that allow for the rapid administration of blood products in fixed ratios during severe bleeding. In pediatric trauma, implementing MTPs that prioritize a 1:1 pRBC:FFP ratio can improve blood product availability, speed up transfusions, reduce reliance on lab results, and simplify decision-making during critical situations. This is particularly important as it addresses the challenges of managing coagulopathy and optimizing oxygen delivery in severely injured children. MTP are designed to reduce mortality and improve patient outcomes.

What evidence supports the use of a 1:1 pRBC:FFP ratio in pediatric trauma, and what were the key findings of the ATOMAC Level I Pediatric Trauma Centers study?

A multi-center retrospective study from the ATOMAC (Arizona, Texas, Oklahoma, Memphis, Arkansas Consortium) Level I Pediatric Trauma Centers (PTC) reviewed data from pediatric trauma patients and found a strong correlation between the pRBC:FFP transfusion ratio and survival rates. Specifically, children receiving a 1:1 pRBC:FFP ratio had the highest survival rates, while ratios of 2:1 or ≥3:1 were associated with a significantly increased risk of death. These findings support the adoption of 1:1 transfusion protocols in pediatric trauma settings to improve outcomes.