Pediatric Traumatic Hemorrhagic Shock Consensus Conference Research Priorities

Russell, Robert T.; Bembea, Melania M.; Borgman, Matthew A.; Burd, Randall S.; Gaines, Barbara A.; Jafri, Mubeen; Josephson, Cassandra D.; Leeper, Christine M.; Leonard, Julie C.; Muszynski, Jennifer A.; Nicol, Kathleen; Nishijima, Daniel K.; Stricker, Paul A.; Vogel, Adam M.; Wong, Trisha E.; Spinella, Philip C.

doi:10.1097/ta.0000000000003802

Cited by 12 publications

(14 citation statements)

References 87 publications

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“…Based on a systematic review and a consensus meeting, the committee noted that empiric TXA may be considered for pediatric trauma 1 . However, there remains several questions that have yet to be answered 34 . First, it is unclear what the appropriate TXA dose is in children and exactly when it should be given for trauma.…”

Section: Discussionmentioning

confidence: 99%

Tranexamic Acid in Pediatric Hemorrhagic Trauma

Borgman

Nishijima

2022

J Trauma Acute Care Surg

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There is strong evidence in adult literature that tranexamic acid (TXA) given within 3 hours from injury is associated with improved outcomes. The evidence for TXA use in injured children is limited to retrospective studies and one prospective observational trial. Two studies in combat settings and one prospective civilian US study have found association with improved mortality. These studies indicate the need for a randomized controlled trial to evaluate the efficacy of TXA in injured children and to clarify appropriate timing, dose and patient selection. Additional research is also necessary to evaluate trauma-induced coagulopathy in children. Recent studies have identified three distinct fibrinolytic phenotypes following trauma (hyperfibrinolysis, physiologic fibrinolysis, and fibrinolytic shutdown), which can be identified with viscohemostatic assays. Whether viscohemostatic assays can appropriately identify children who may benefit or be harmed by TXA is also unknown. (

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Section: Discussionmentioning

confidence: 99%

Tranexamic Acid in Pediatric Hemorrhagic Trauma

Borgman

Nishijima

2022

J Trauma Acute Care Surg

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“…Currently, there is variability in TXA use in MTPs despite a favourable safety profile [47,48 ▪ ]. The Pediatric Trauma Hemorrhagic Shock Consensus Conference recommends TXA be considered in paediatric trauma [49 ▪ ].…”

Section: Damage Control Resuscitationmentioning

confidence: 99%

Balanced resuscitation: application to the paediatric trauma population

Georgette

Lipton

2023

Current Opinion in Pediatrics

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Purpose of reviewTrauma is the leading cause of death in children over 5 years old. Early mortality is associated with trauma-induced coagulopathy (TIC), with balanced resuscitation potentially mitigating the effects of TIC. We review TIC, balanced resuscitation and the best evidence for crystalloid fluid versus early blood products, massive transfusion protocol (MTP) and the optimal ratio for blood products.Recent findingsCrystalloid fluids have been associated with adverse events in paediatric trauma patients. However, the best way to implement early blood products remains unclear; MTP has only shown improved time to blood products without clear clinical improvement. The indications to start blood products are also currently under investigation with several scoring systems and clinical indications being studied. Current studies on the blood product ratio suggest a 1 : 1 ratio for plasma:pRBC is likely ideal, but prospective studies are needed to further support its use.SummaryBalanced resuscitation strategies of minimal crystalloid use and early administration of blood products are associated with improved morbidity in paediatric trauma patients but unclear mortality benefit. Current evidence suggests that the utilization of MTPs with 1 : 1 plasma:pRBC ratio may improve morbidity, but more research is needed.

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“…These studies suggest the safety and feasibility of PHT, but clinical benefit has yet to be elucidated. Given the paucity of high-quality research on early resuscitation strategies in injured children, the Pediatric Traumatic Hemorrhagic Shock Consensus Conference proposed several research priorities regarding pediatric traumatic hemorrhagic shock, which included improving recognition and identifying most effective treatment of hemorrhagic shock in children . This current study aligns with this research priority and was performed to determine if PHT is associated with decreased mortality in injured children using a statewide trauma database.…”

Section: Introductionmentioning

confidence: 99%

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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Pediatric Traumatic Hemorrhagic Shock Consensus Conference Research Priorities

Cited by 12 publications

References 87 publications

Tranexamic Acid in Pediatric Hemorrhagic Trauma

Tranexamic Acid in Pediatric Hemorrhagic Trauma

Balanced resuscitation: application to the paediatric trauma population

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

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