Emergency Department Initiated Versus Trauma Team Initiated Massive Transfusion Protocols After Injury: A Review of Activation, Time to Transfusion, and Clinical Outcomes

Background: Massive transfusion protocols coordinate urgent blood delivery after injury. Activation authority varies in trauma systems and frequently overlaps between emergency physicians and trauma teams. This review examined activation practices, transfusion timing, and clinical outcomes. Methods: Ten original studies published before June 2026 were examined through structured narrative synthesis. Evidence addressed clinician decisions, prehospital activation, automatic activation, blood delivery, and protocol implementation. Direct specialty comparisons were distinguished from indirect workflow data. Results: One prospective cohort reported transfusion initiation by trauma surgeons in 35% and emergency clinicians in 19%, without comparative specialty outcomes. A multicenter analysis associated each additional minute to initial cooler delivery with increased adjusted mortality odds. Simulation informed improvement reduced activation to blood administration from 11.6 to 9.1 minutes. Implementation cohorts reported faster blood availability, with inconsistent mortality findings. A contemporary cohort documented protocol reactivation in 7.5% of patients, illustrating the importance of reassessment after initial activation. Conclusion: Data supports rapid recognition, coordinated activation, and efficient transfusion delivery after injury in routine clinical practice. Comparative research requires clinician attribution, standardized timing intervals, and adjustment for injury severity, shock, blood availability, and resuscitation changes in participating trauma systems and different treatment environments.