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Background:Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation.Design and method:This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion.Results:Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of 1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy.Conclusions:A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.