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Abstract: Background: There is limited evidence to guide the recognition of patients with massive, uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol. Objective: To risk stratify patients with major trauma and to predict need for MT. Designs: Retrospective analysis of an administrative trauma database of major trauma patients. A regional trauma Centre: A regional trauma centres in Hong Kong. Patients: Patients with Injury Severity Score ≥9 and age ≥12 years were included. Burn patients, patients with known severe anemia and renal failure, or died within 24h were excluded. Main outcome measures: Delivery of ≥10 units of packed red blood cells (RBC) within 24h. Results: Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients required ≥10 units RBC within 24h. Seven variables which were easy to be measured in the ED and significantly predicted the need for MT are heart rate ≥120/min; systolic blood pressure ≤90mmHg; Glasgow coma scale ≤8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5mmol/L; hemoglobin ≤7g/dL; and hemoglobin 7.1–10g/dL. At a cut off of ≥6, the overall correct classification for predicting need for MT was 96.9%, with a sensitivity of 31.5% and specificity of 99.7%, and an incidence of MT of 82.9%. The area under the curve was 0.889. Conclusion: A prediction rule for determining an increased likelihood for the need for massive transfusion has been derived. This needs validation in an independent data set. [Copyright &y& Elsevier]