Background: Early transfusion of blood products for severely injured patients can improve volume depletion, acidosis, dilution and coagulopathy. There is concern that some patients are unnecessarily exposed to the risks of emergent transfusion with uncrossmatched red blood cell products (URBC) in the emergency department (ED). The goal of this study was to evaluate the transfusion practices in our ED among all patients who received URBC. Methods:We analyzed all injured patients transfused at least 1 URBC in the ED at a level-1 trauma centre between Jan. 15, 2007, and Jan. 14, 2008. Demographics, injuries and outcomes were reported. We used standard statistical methodology. Results: At least 1 URBC product was transfused into 153 patients (5% of all patients, mean 2.6 products) in the ED (median Injury Severity Score [ISS] 28; hemodynamic instability 94%). Sixty-four percent of patients proceeded to an emergent operation and 17% required massive transfusion. The overall mortality rate was 45%, which increased to 52% and 100% in patients who received 4 and 5 or more URBC products, respectively. Nonsurvivors had a higher median ISS (p = 0.017), received more URBC in the ED (p = 0.006) and possessed more major vascular injuries (p < 0.001). Among nonsurvivors, 67% died of uncontrollable hemorrhage. Unnecessary URBC transfusions in the ED occurred in 7% of patients. Conclusion: Overtransfusion was minimal based on clinical acumen triggers. Early transfer of patients receiving URBC products in the ED to the operating room, intensive care unit or angiography suite for ongoing resuscitation and definitive hemorrhage control must be strongly considered.