Early plasma administration in traumatic brain injuries: A systematic review

Early plasma may improve trauma resuscitation by addressing shock and coagulopathy, but its role in traumatic brain injury (TBI) remains uncertain. This systematic review evaluated early plasma in TBI.

This review followed Cochrane methodology and was registered in PROSPERO (CRD420261357882). MEDLINE, Embase, Cochrane databases, and Web of Science were searched on February 3, 2026 and rerun August 11, 2026. Comparative studies of prehospital or early in-hospital plasma in TBI were eligible. Risk of bias was assessed using RoB-2 and ROBINS-I, certainty using GRADE, and findings were synthesized narratively.

Fifteen studies including 183,253 patients were included. Studies varied in design, population, plasma product, timing, dose, comparator, and outcomes. A secondary analysis of a cluster-randomized trial found lower 24-h and 30-day mortality with prehospital plasma among patients at risk of hemorrhagic shock subsequently found to have CT-confirmed TBI; the association was observed among direct scene transports but not interfacility transfers, suggesting timing relative to injury may be important. Two small early in-hospital trials showed no mortality benefit; one reported similar mortality with plasma and saline, while the other reported higher mortality and more delayed or new intracranial hematomas with plasma. Observational findings were inconsistent and limited by confounding by indication, with variation by plasma timing, comparator, and TBI severity. Certainty of evidence was very low.

Evidence is insufficient to determine whether early plasma benefits or harms patients with TBI. Future randomized trials should standardize indications, time-to-plasma, plasma protocols, and outcomes and clarify clinically relevant plasma timing windows.