PURPOSE OF REVIEW: Severe trauma is associated with hemorrhage, coagulopathy and transfusion of blood and blood products, all associated with considerable mortality and morbidity. The aim of this review is to focus on resuscitation, transfusion strategies and the management of bleeding in trauma as well as to emphasize on why coagulation has to be monitored closely and to discuss the rationale of modern and future transfusion strategies. RECENT FINDINGS: Coagulopathy and uncontrolled bleeding remain leading causes of death in trauma, lead to blood transfusions and increased mortality as it has been recently shown that blood transfusion per se results in an adverse outcome. In the last years, damage control resuscitation, a combination of permissive hypotension, hemostatic resuscitation and damage control surgery, has been introduced to treat severely traumatized patients in hemorrhagic shock. Goals of treatment in trauma patients remain avoiding metabolic acidosis, hypothermia, treating coagulopathy and stabilizing the patient as soon as possible. The place of colloids and crystalloids in trauma resuscitation as well as the role of massive transfusion protocols with a certain FFP : RBC ratio and even platelets have to be reevaluated. SUMMARY: Close monitoring of bleeding and coagulation in trauma patients allows goal-directed transfusions and thereby optimizes the patient's coagulation, reduces the exposure to blood products, reduces costs and may improve clinical outcome.