The critically injured trauma patient in severe hemorrhagic shock presents a complex and arduous challenge to even the most experienced trauma staff. Lives are at stake as trauma teams feverishly pour massive amounts of blood into severely injured patients attempting to replace entire blood volumes several times over. Prompt identification of patients at risk for hemorrhage and establishment of massive transfusion protocols can provide guidance in managing the transfusion needs of the exsanguinating patient. These state-of-the-art protocols address component therapy, endpoints to transfusion and complications related to massive transfusions. Other treatments, such as autotransfusion and blood substitutes, are promising adjunctive therapies that may in the near future help to improve outcomes in patients who require massive blood transfusions. This article reviews the current standard of care for the trauma patient requiring massive transfusion.