Massive bleeding in polytrauma: how can we make progress?

Trauma is a major cause of death worldwide, with some 30% of deaths associated with hemorrhage. Rapid control of bleeding in such patients is thus an essential aspect of trauma care. Recombinant human factor VIIa is sometimes used off-label in massively bleeding patients and has been demonstrated in two randomized trials to significantly reduce the need for blood transfusions. Whether this translates into improved outcomes has not been determined, most notably because mortality appears to be much lower than in the past as a result of improved general care of trauma patients. In this setting it may be increasingly difficult to demonstrate that any intervention can influence survival since the number of patients needed for sufficient power is so high and the duration needed for recruitment of the patients too long. In the present commentary, we reflect on how we can move forward in the management of severely bleeding trauma patients in the current environment.