Over a 54-month period 6,142 patients were consecutively admitted to our Level I trauma center. Ninety-two blunt trauma patients required massive transfusion (MT) of 20 or more units of packed red blood cells (range, 20–126). Eighty-two per cent of all transfused blood was given within 24 hours of admission. Forty-eight patients (52%) were long-term survivors. Twenty-six patients died (28%) within 24 hours and 21 of these exsanguinated. Eighteen patients died > 24 hours: nine (50%) died from multiple organ failure, and nine (50%) died from severe closed head injury (CHI). Clinical predictors of increased mortality were: shock on admission, closed head injury, and age.Forty-three survivors were followed for a mean of 2.5 years (range, 1–5 years). No patient died during followup. All patients were home at 1 year; only four patients required continued medical assistance. Thirty-two patients (74%) returned to work. We conclude that: 1) blunt and penetrating trauma patients receiving MT have similar survival rates of 50%; 2) shock, closed head injury, and age predict increased mortality but do not preclude survival: 3) long-term outcome in blunt patients requiring MT is excellent. Post-discharge death is rare and 3/4 of the survivors return to work, justifying the high cost of acute care.