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The objective of this study was to determine the optimal use of fresh-frozen plasma (FFP) in trauma. Our hypothesis was that a higher FFP: packed red blood cells (PRBC) ratio is associated with improved survival.This is a 6-year retrospective trauma registry and blood bank database study in a level I trauma center. All massively transfused patients (≥10 PRBC during 24 hours) were analyzed. Patients with severe head trauma (head Abbreviated Injury Severity score ≥3) were excluded from the analysis. Patients were classified into four groups according to the FFP:PRBC ratio received: low ratio (≤1:8), medium ratio (>1:8 and ≤1:3), high ratio (>1:3 and ≤1:2), and highest ratio (>1:2).Of 25,599 trauma patients, 4,241 (16.6%) received blood transfusion. Massive transfusion occurred in 484 (11.4%) of the transfused. After exclusion of 101 patients with severe head injury 383 patients were available for analysis. The mortality rate decreased significantly with increased FFP transfusion. However, there does not seem to be a survival advantage after a 1:3 FFP:PRBC ratio has been reached. Using the highest ratio group as a reference, the relative risk of death was 0.97 (p = 0.97) for the high ratio group, 1.90 (p < 0.01) for the medium ratio group, and 3.46 (p < 0.01) for the low ratio group. There was an increasing trend toward more FFP use during time with the mean units per patient increasing 83% from 6.3 ± 4.6 in 2000 to 11.5 ± 9.7 in 2005.Higher FFP:PRBC ratio is an independent predictor of survival in massively transfused patients. Aggressive early use of FFP may improve outcome in massively transfused trauma patients.