ObjectiveHigh ratio of plasma to red blood cells during massive transfusion is associated with improved survival of traumatic injuries in adults, but this has not been demonstrated in children. Our objective was to compare the outcome of children who received high (≥1:2) versus low (<1:2) plasma: red blood cells (P:R) ratios at 24 h from injury.MethodsWe conducted a retrospective chart review of children <18 years of age who presented to the emergency department over a 7-year period and received massive transfusion (≥40 ml/kg red blood cells or ≥80 ml/kg total blood products in 24 h). Our primary outcome of interest was in-hospital mortality.ResultsWe identified 38 children who received massive transfusion. There was no significant difference in in-hospital mortality (45.8% vs. 64.3%) between the high (n = 24, median ratio 1:1.1) and low P:R ratio (n = 14, median 1:3.2) groups. In subset analyses, there was reduced mortality for high P:R patients with BIG score ≥24 (69.2% vs. 100%) and those taken to the operating room within 6 h of arrival (21.4% vs. 60.0%), respectively ( p < 0.05). There was a trend for improved survival in high P:R patients without severe traumatic brain injury (TBI) (0% vs. 40.0%).ConclusionsThis study suggests that high P:R transfusion may improve in-hospital survival of injured children at high risk of mortality and in children without severe TBI, supporting the need for large, multi-center studies.