Background: Major hemorrhage in surgical trauma patients presents a complex challenge, where transfusion strategies significantly influence both patient outcomes and resource stewardship. The optimal ratio of blood components-particularly packed red blood cells (PRBCs), fresh frozen plasma (FFP), and platelets-remains a critical area of investigation. Balanced transfusion approaches (e.g., 1:1:1 ratios) aim to correct trauma-induced coagulopathy early but may increase blood product usage. Conversely, restrictive or guided strategies might conserve resources but risk inadequate hemostatic support. Objective: This study aimed to compare the effects of a balanced transfusion strategy versus a viscoelastic hemostatic assay (VHA)-guided strategy on coagulation function, blood product consumption, and clinical outcomes in surgical trauma patients with major hemorrhage. Methods: A prospective, randomized controlled trial was conducted at a Level I trauma center. Adult patients with major traumatic hemorrhage requiring massive transfusion protocol (MTP) activation were randomized to: 1) Balanced Group: receiving PRBC:FFP:platelets in a 1:1:1 ratio until MTP was terminated, or 2) VHA-Guided Group: where transfusion of FFP, platelets, and fibrinogen concentrate was directed by real-time thromboelastometry (ROTEM®). Primary outcomes were the proportion of patients achieving hemostatic competence (defined as stable clot formation on ROTEM and controlled surgical bleeding) within 6 hours, and total units of allogeneic blood products transfused in the first 24 hours. Secondary outcomes included mortality (24-hour, 30-day), incidence of thromboembolic events, multiple organ dysfunction syndrome (MODS), and ICU length of stay. Results: 120 patients were randomized (60 per group). The VHA-guided group achieved hemostatic competence significantly faster than the balanced group (median 2.8 vs. 4.1 hours, p<0.01) and received 35% fewer total units of allogeneic blood products in the first 24 hours (median 18 vs. 28 units, p<0.001). This reduction was primarily driven by significantly lower use of FFP and platelets. There was no significant difference in 24-hour mortality (8.3% vs. 11.7%, p=0.53) or 30-day mortality (20.0% vs. 23.3%, p=0.66). However, the VHA-guided group had a lower incidence of MODS (18.3% vs. 33.3%, p=0.048) and a non-significant trend towards fewer thromboembolic events (5.0% vs. 11.7%, p=0.18). Conclusion: In surgical trauma patients with major hemorrhage, a ROTEM-guided transfusion strategy, compared to a fixed-ratio balanced strategy, leads to more rapid correction of coagulopathy with significantly reduced consumption of plasma and platelet components, without compromising survival. This targeted approach optimizes coagulation function while promoting efficient blood resource utilization, supporting its integration into trauma resuscitation protocols.