Fresh frozen plasma-first approach is independently associated with improved survival in severely injured patients undergoing massive transfusion

BACKGROUND: Despite evidence supporting high fresh frozen plasma (FFP)–to–packed red blood cell (PRBC) ratios, the optimal initial blood product in severe injury is unknown. We hypothesized that an FFP-first approach is associated with improved survival. METHODS: An observational Trauma Quality Improvement Program (2013–2021), including patients who received at least 5 units of PRBCs and 1 unit of FFP within four hours of arrival, was performed. Nonsurvivable injury patterns and pre-existing coagulopathy were excluded. Treatment effects were estimated with propensity score-weighted risk adjustment models, clustering by center. The primary outcome was six-hour mortality. Secondary outcomes were 24-hour and in-hospital mortality. A subanalysis was performed on the severe head-injured, and a sensitivity analysis examined inclusion criteria and additional blood products (platelets and cryoprecipitate). Effect modification was assessed for injury type. RESULTS: A total of 50,580 patients were included, with 13,818 in the FFP-first approach. Mean age was 39 years, with 77% males, 60% blunt trauma, and a mean Injury Severity Score of 27. Subanalysis included 15,912 patients, and the exposure sensitivity analysis included 27,217 patients. Unadjusted six-hour, 24-hour, and in-hospital mortality for the PRBC-first approach were 9.8%, 15%, and 28%, respectively, compared with 8.9%, 14%, and 27% for the FFP-first approach. A PRBC approach was independently associated with worse six-hour (adjusted Odds Ratio [aOR], 1.10; 95% CI, 1.02–1.18), 24-hour (1.11; 1.05–1.18), and in-hospital mortality (1.06; 1.01–1.11). The subgroup analysis of the PRBC aOR was 1.08 (95% CI, 0.95–1.23). In the exposure sensitivity analysis, the PRBC aOR was 1.02 (95% CI, 0.94–1.09). The blood products analysis was congruent with the main analysis. Effect modification was not present for injury type; however, penetrating mechanism was significantly associated with early death. CONCLUSIONS: Although the effect was modest in magnitude, a FFP-first approach was independently associated with improved survival through hospital discharge. Future prospective or randomized trials are warranted. ( J Trauma Acute Care Surg 2026;00:000–000.