Hemostatic Resuscitation of Pediatric Trauma Patients During Air Medical Transport: A Retrospective Matched Cohort Study

Dijck, Cedric P. Van; Stansbury, Lynn G.; Latimer, Andrew J.; Butler, Eric; Nathwani, Rajen; Wall, Jessica; Utarnachitt, Richard B.; Vavilala, Monica S.; Hess, John R.

doi:10.1016/j.amj.2021.04.004

Cited by 10 publications

(12 citation statements)

References 29 publications

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“…Prehospital transfusions are rare in the pediatric population, and data are primarily limited to small, retrospective, single-center studies. Although limited, these studies have shown that prehospital transfusion of injured children is safe, feasible, and associated with improvement in markers of coagulopathy and shock 25–28 . While multicenter prospective studies are needed, the available data suggest that the timing of blood product resuscitation is important.…”

Section: Prehospital Transfusionsmentioning

confidence: 99%

“…Although limited, these studies have shown that prehospital transfusion of injured children is safe, feasible, and associated with improvement in markers of coagulopathy and shock. [25][26][27][28] While multicenter prospective studies are needed, the available data suggest that the timing of blood product resuscitation is important. Of equal importance may be the type of blood product used for initial resuscitation of hemorrhagic shock in injured children.…”

Section: Prehospital Transfusionsmentioning

confidence: 99%

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Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma

Morgan

Leeper

Yazer

et al. 2022

J Trauma Acute Care Surg

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Increasing rates of penetrating trauma in the United States makes rapid identification of hemorrhagic shock, coagulopathy, and early initiation of balanced resuscitation in injured children of critical importance. Hemorrhagic shock begins early after injury and can be challenging to identify in children, as hypotension is a late sign that a child is on the verge of circulatory collapse and should be aggressively resuscitated. Recent data support shifting away from crystalloid and toward early resuscitation with blood products because of worse coagulopathy and clinical outcomes in injured patients resuscitated with crystalloid. Multicenter studies have found improved survival in injured children who receive balanced resuscitation with higher fresh frozen plasma: red blood cell ratios. Whole blood is an efficient way to achieve balanced resuscitation in critically injured children with limited intravenous access and decreased exposure to multiple donors. Administration of cold-stored, low-titer O-negative whole blood (LTOWB) appears to be safe in adults and children and may be associated with improved survival in children with life-threatening hemorrhage. Many pediatric centers use RhD-negative LTOWB for all female children because of the risk of hemolytic disease of the fetus and newborn (0-6%); however. there is a scarcity of LTOWB compared with the demand. Low risks of hemolytic disease of the fetus and newborn affecting a future pregnancy must be weighed against high mortality rates in delayed blood product administration in children in hemorrhagic shock. Survey studies involving key stakeholder's opinions on pediatric blood transfusion practices are underway. Existing pediatric-specific literature on trauma resuscitation is often limited and underpowered; multicenter prospective studies are urgently needed to define optimal resuscitation products and practices in injured children in an era of increasing penetrating trauma.

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Section: Prehospital Transfusionsmentioning

confidence: 99%

Section: Prehospital Transfusionsmentioning

confidence: 99%

Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma

Morgan

Leeper

Yazer

et al. 2022

J Trauma Acute Care Surg

View full text Add to dashboard Cite

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“…Only two studies have compared outcomes between matched pediatric cohorts who received blood products prehospital versus in-hospital. These studies are limited by sample size and moderate bias because of outcome measurement and confounding 50,51 . Although the studies were not adequately powered to detect a difference in mortality, authors did report that the prehospital transfusion groups did receive less in-flight crystalloid and had higher admission fibrinogen levels and faster time to normalization of the international normalized ratio 51 .…”

Section: Methodsmentioning

confidence: 99%

“…These studies are limited by sample size and moderate bias because of outcome measurement and confounding. 50,51 Although the studies were not adequately powered to detect a difference in mortality, authors did report that the prehospital transfusion groups did receive less in-flight crystalloid and had higher admission fibrinogen levels and faster time to normalization of the international normalized ratio. 51 This recommendation has to take into account the ability of blood products and comfort level of the practice of regional EMSs.…”

Section: Rationalementioning

confidence: 99%

“…50,51 Although the studies were not adequately powered to detect a difference in mortality, authors did report that the prehospital transfusion groups did receive less in-flight crystalloid and had higher admission fibrinogen levels and faster time to normalization of the international normalized ratio. 51 This recommendation has to take into account the ability of blood products and comfort level of the practice of regional EMSs. However, the previous literature suggests that there is evidence that this can be organized and safely used in pediatric trauma patients with hemorrhagic shock.…”

Section: Rationalementioning

confidence: 99%

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Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations

Russell

Esparaz

Beckwith

et al. 2022

J Trauma Acute Care Surg

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Hemorrhagic shock in pediatric trauma patients remains a challenging yet preventable cause of death. There is little high-quality evidence available to guide specific aspects of hemorrhage control and specific resuscitation practices in this population. We sought to generate clinical recommendations, expert consensus, and good practice statements to aid providers in care for these difficult patients. The Pediatric Traumatic Hemorrhagic Shock Consensus Conference process included systematic reviews related to six subtopics and one consensus meeting. A panel of 16 consensus multidisciplinary committee members evaluated the literature related to 6 specific topics: (1) blood products and fluid resuscitation for hemostatic resuscitation, (2) utilization of prehospital blood products, (3) use of hemostatic adjuncts, (4) tourniquet use, (5) prehospital airway and blood pressure management, and (6) conventional coagulation tests or thromboelastography-guided resuscitation. A total of 21 recommendations are detailed in this article: 2 clinical recommendations, 14 expert consensus statements, and 5 good practice statements. The statement, the panel's voting outcome, and the rationale for each statement intend to give pediatric trauma providers the latest evidence and guidance to care for pediatric trauma patients experiencing hemorrhagic shock.With a broad multidisciplinary representation, the Pediatric Traumatic Hemorrhagic Shock Consensus Conference systematically evaluated the literature and developed clinical recommendations, expert consensus, and good practice statements concerning topics in traumatically injured pediatric patients with hemorrhagic shock.

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Association of Prehospital Transfusion With Mortality in Pediatric Trauma

et al. 2023

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ImportanceOptimal hemostatic resuscitation in pediatric trauma is not well defined.ObjectiveTo assess the association of prehospital blood transfusion (PHT) with outcomes in injured children.Design, Setting, and ParticipantsThis retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023.ExposureReceipt of a blood product transfusion in the prehospital setting compared with the emergency department.Main Outcomes and MeasuresThe primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications.ResultsOf 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child’s life was 5 (95% CI, 3-10).Conclusions and RelevanceIn this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

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Hemostatic Resuscitation of Pediatric Trauma Patients During Air Medical Transport: A Retrospective Matched Cohort Study

Cited by 10 publications

References 29 publications

Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma

Resuscitative practices and the use of low-titer group O whole blood in pediatric trauma

Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

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