IMPORTANCEAlthough most massive transfusion protocols incorporate cryoprecipitate in the treatment of hemorrhaging injured patients, minimal data exist on its use in children, and whether its addition improves their survival is unclear.OBJECTIVE To determine whether cryoprecipitate use for injured children who receive massive transfusion is associated with lower mortality. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study included injured patients examined between January 1, 2014, and December 31, 2017, at one of multiple centers across the US and Canada participating in the Pediatric Trauma Quality Improvement Program. Patients were aged 18 years or younger and had received massive transfusion, which was defined as at least 40 mL/kg of total blood products in the first 4 hours after emergency department arrival. Exclusion criteria included hospital transfer, arrival without signs of life, time of death or hospital discharge not recorded, and isolated head injuries. To adjust for potential confounding, a propensity score for treatment was created and inverse probability weighting was applied. The propensity score accounted for age, sex, race/ethnicity, injury type, payment type, Glasgow Coma Scale score, hypoxia, hypotension, assisted respirations, chest tube status, Injury Severity Score, total volume of blood products received, hemorrhage control procedure, hospital size, academic status, and trauma center designation. Data were analyzed from December 11, 2019, to August 31, 2020.EXPOSURES Cryoprecipitate use within the first 4 hours of emergency department arrival. MAIN OUTCOMES AND MEASURESIn-hospital 24-hour and 7-day mortality. RESULTSOf the 2387 injured patients who received massive transfusion, 1948 patients were eligible for analysis. The median age was 16 years (interquartile range, 9-17 years), 1382 patients (70.9%) were male, and 807 (41.4%) were White. A total of 541 patients (27.8%) received cryoprecipitate. After propensity score weighting, patients who received cryoprecipitate had a significantly lower 24-hour mortality when compared with those who did not (adjusted difference, −6.9%; 95% CI, −10.6% to −3.2%). Moreover, cryoprecipitate use was associated with a significantly lower 7-day mortality but only in children with penetrating trauma (adjusted difference, −9.2%; 95% CI, −15.4% to −3.0%) and those transfused at least 100 mL/kg of total blood products (adjusted difference, −7.7%; 95% CI, −15.0% to −0.5%). CONCLUSIONS AND RELEVANCEIn this cohort study, early use of cryoprecipitate was associated with lower 24-hour mortality among injured children who required massive transfusion. The benefit of cryoprecipitate appeared to persist for 7 days only in those with penetrating trauma and in those who received extremely large-volume transfusion.

Objective The goal was to determine the effects of specialty training and practice settings on the adherence to the Pediatric Emergency Care Applied Research Network (PECARN) criteria. Methods A retrospective study was conducted on a 2-campus hospital. Chart documentation was used to determine adherence to PECARN criteria. Inclusion criteria were any traumatic head injury within 24 hours in patients younger than 18 years over a 1-year period. Specialty training was subdivided into 3 groups: pediatric emergency medicine, emergency medicine (EM), and general pediatrics. The 2 hospital campuses are distinctly different practice settings, one being an academic practice setting, which is also a trauma center that has a dedicated pediatric emergency department, staffed by pediatric emergency medicine, EM, and general pediatrics physicians, and the second campus is a community practice and is staffed solely by EM physicians. Statistical analysis was performed using χ2 and Cochran-Mantel-Haenszel tests. All analyses were 2-sided, and P < 0.05 was considered statistically significant. Results A total of 709 pediatric patients with traumatic head injuries were analyzed. Overall adherence to PECARN criteria was 93%. No statistical difference was found between different specialty training on the academic campus. In addition, the rate of adherence among EM physicians at the academic and community settings was 94.8% versus 86.5%, respectively (P = 0.004). Conclusions Practice setting had an effect on adherence to PECARN criteria in pediatric patients with acute traumatic head injury. The same determination on adherence was not demonstrated among physicians with different specialty trainings.

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