Patients with massive hemorrhage, when it is uncontrolled for any length of time, often develop metabolic failure, more commonly referred to as the “triad of death”: hypothermia, acidosis, and coagulopathy. In the present paradigm, coagulopathy and ongoing hemorrhage are both contributor and outcome of the metabolic failure, which carries a high mortality rate. In one series of more than 17 000 trauma patients, 82% of early in-hospital deaths were attributed to metabolic failure.8 Cosgriff et al9 showed that the presence of hypothermia and acidosis in a bleeding patient predicts the development of life-threatening coagulopathy and that combinations exponentially increased the occurrence up to 98% if all 4 factors, hypotension, Injury Severity Score higher than 25, hypothermia, and acidosis, were present.9 Consequently, interventions such as the abbreviated or “damage control” laparotomy are routinely used to aggressively treat hypothermia, acidosis, and blood loss first rather than extended surgical repairs of anatomical injuries. This approach has been reported to increase survival in the range of 20% to 60%.10,11 Therefore, an important interplay between these 3 factors, acidosis, hypothermia, and coagulopathy, appears to occur in the patient with massive blood loss culminating in a severe clinical coagulopathy and a nonsurvivable metabolic deterioration and death. In our present concept of the development of trauma-related coagulopathy, how does each of these 3 factors relate?