BACKGROUND:Although hemostatic resuscitation with a 1:1 ratio of fresh-frozen plasma (FFP) to packed red blood cells (PRBC) after severe hemorrhage has been shown to improve survival, its benefit in patients with traumatic-induced coagulopathy (TIC) after >10 units of PRBC during operation has not been elucidated. We hypothesized that a survival benefit would occur when early hemostatic resuscitation was used intraoperatively after injury in patients with TIC. METHODS:A 7-year retrospective study of patients with emergency department diagnosis of TIC after transfusion of >10 units of PRBC in the operating room. TIC was defined as initial emergency department international normalized ratio > 1.2, prothrombin time > 16 seconds, and partial thromboplastin time > 50 seconds. Patients were divided into FFP:PRBC ratios of 1:1, 1:2, 1:3, and 1:4. Patients with diagnosis of TIC who received transfusion of both FFP and PRBC during surgery were included. Other variables evaluated included age, gender, mechanism of injury, initial base deficit, mean operative time, trauma intensive care unit length of stay (TICU LOS) and Injury Severity Score. The primary outcome measure evaluated was the impact of the early FFP:PRBC ratio on mortality. RESULTS:Four hundred thirty-five patients underwent emergency operations postinjury and received FFP with >10 units of PRBC in the operating room; 135 (31.0%) of these patients had TIC and 53 died (39.5% mortality). Mean operative time was 137 minutes (SD +/- 49). There were no differences with regard to age, gender, mechanism of injury, initial base deficit, or Injury Severity Score among all groups. A significant difference in mortality was found in patients who received >10 units of PRBC when FFP:PRBC ratio was 1:1 versus 1:4 (28.2% vs. 51.1%, p = 0.03). Intermediate mortality rates were noted in patients with 1:2 and 1:3 ratios (38% and 40%, respectively). From a linear regression model, 13 days of increased TICU LOS was observed among 1:4 group compared with 1:1 group (p < 0.01). CONCLUSION:TIC is common after severe injury and is associated with a high mortality in patients transfused with >10 units of PRBC during surgery. Early hemostatic resuscitation during first hours after injury improves survival with shorter TICU LOS in patients with TIC.