High-ratio plasma resuscitation decreases mortality in moderate traumatic brain injury

Traumatic brain injury (TBI) is a leading cause of trauma-related mortality. While high ratios of fresh frozen plasma (FFP):red blood cells (RBC) improve survival in hemorrhagic shock, the role of FFP in polytrauma patients with TBI not requiring massive transfusion is unclear. We hypothesized that higher FFP ratios would be associated with improved early and late survival across TBI severities.

Adult trauma patients (age 18 or older) with suspected TBI (head AIS ≥1) who received ≥1 unit of blood product from 2020 to 2021 were identified in the American College of Surgeon's Trauma Quality Improvement Project database. Burns, interfacility transfers, and massive transfusion (≥5 RBC-containing units within 4 hours) were excluded. Patients were stratified by head AIS (mild 1-2, moderate 3-4, and severe 5-6). FFP ratio was calculated as FFP:total transfused blood products, and patients were categorized as receiving no FFP, low FFP, or high FFP, with the median of non-zero FFP ratios used to divide low from high. Multivariable logistic regression was performed to assess the association between FFP ratios and 6-hour and 30-day mortality. Subgroup analyses of isolated TBI patients and sensitivity analyses excluding whole blood recipients were performed.

In 23,362 patients, 40.1% had mild TBI, 35.9% moderate, and 24.0% severe. Overall, 6-hour and 30-day mortality rates were 12.6% and 32.4%, respectively. High FFP ratios were associated with lower 6-hour mortality in moderate and severe TBI, with a sustained 30-day survival benefit only in moderate TBI. Low FFP ratios decreased only early mortality in moderate and severe TBI. Subgroup and sensitivity analyses demonstrated the greatest survival benefit in moderate TBI.

The association between FFP and mortality varies across TBI severity groups and proportions of FFP given in initial resuscitation. These findings suggest that moderate TBI patients may benefit most from high-ratio FFP resuscitation. ( J Trauma Acute Care Surg . 2026;101: 241-248. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.).

Therapeutic/Care Management; Level III.