Association of plasma transfusion timing with mortality among patients with traumatic intracranial hemorrhage across US adult civilian trauma centers.
The journal of trauma and acute care surgery · 2026-04-20 · Observational study
Abstract
BACKGROUND: Traumatic intracranial hemorrhage (ICH) is a major driver of traumatic brain injury-related mortality. Although plasma transfusion has been associated with improved survival in these patients, the timing of transfusion influences outcomes is unclear. We sought to determine how plasma transfusion timing affects survival in patients with tICH, hypothesizing that earlier transfusion improves outcomes and that there is a threshold after which survival benefits diminish. METHODS: We conducted a retrospective analysis of adult trauma patients (≥18 y) with tICH who received plasma-based resuscitation within 4 hours of ED arrival between 2020 and 2021 from the ACS-TQIP database. Patients with prehospital cardiac arrest, anticoagulant therapy, nonsurvivable head injuries, and interfacility transfers were excluded. The multivariable Royston-Parmar flexible parametric regression model assessed the primary outcome of 30-day mortality. RESULTS: A total of 6,183 patients were included. Median age was 41 years, 73% were male. Median injury severity score was 34, the median head AIS score was 4, and 88% were blunt mechanisms. The overall in-hospital 30-day mortality was 45%. Survival analysis showed that patients who received plasma transfusion compared with those who had not yet received plasma at similar time points had a 45% lower hazard of death at 30 days (aHR, 0.55; 95% CI: 0.33-0.92; p =0.02). Predicted survival declined sharply in the first 30 minutes, with a 5% absolute decrease per 10-minute delay. Beyond 30 minutes, survival benefit plateaued, and the risk of neurosurgical interventions increased. CONCLUSIONS: Early plasma transfusion within the first 4 hours of ED arrival is associated with improved survival in patients with tICH, with the most pronounced benefit seen when plasma is given within the first 30 minutes. These findings highlight urgent plasma administration as a key element of early resuscitation in TBI and support prospective validation to inform trauma protocols. ( J Trauma Acute Care Surg . 2026;101: 89-96. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.