Prehospital Transfusion in Pediatric Trauma—The Clock Is Ticking

Abstract

Trauma is the leading cause of mortality and hemorrhagic shock in pediatric patients, and sustained injuries are one of the most common causes of preventable mortality in these patients. 1 An estimated 1000 to 2000 preventable traumatic deaths in children per year occur after injury in the US because of inadequate or delayed care. 2 Some of these deaths may represent pediatric patients with unrecognized hemorrhagic shock who are not promptly treated with hemorrhage control and appropriate hemostatic resuscitation. The 30-day mortality in children with traumatic hemorrhagic shock is estimated to be 36% to 50% compared with the 25% reported mortality in similar adults. 3,4 A retrospective review of the Pennsylvania statewide trauma database by Morgan et al 5 aimed to determine if the utilization of prehospital transfusion (PHT) in injured children leads to decreased mortality.Adult data have left no question as to whether prehospital blood transfusions improve mortality. Retrospective military and civilian studies in addition to randomized clinical trials have demonstrated improved 6-hour, 24-hour, and 30-day mortality rates in traumatically injured adults receiving PHT. In addition, these studies have demonstrated improvement in the patient's physiological status on arrival at the hospital, less need for crystalloid administration, and minimal blood product wastage. [6][7][8][9] The Pediatric Traumatic Hemorrhagic Shock Consensus Conference determined, based on the current literature, that it is reasonable to consider PHT for pediatric patients with hemorrhagic shock, but this is a critical research priority. 10,11 Prior to this study, the best available pediatric literature suggests that clinicians should try to limit the use of crystalloid boluses in children with hemorrhagic shock. Increasing the use of crystalloids in children exhibiting signs of shock has led to increased odds of mechanical ventilation and longer intensive care unit and hospital stays. [12][13][14] In addition, small single-center studies have demonstrated that PHT is safe and feasible and improves physiologic measures of coagulopathy and shock. However, owing to the limited sample size of these studies, to our knowledge, no study has demonstrated an improvement in mortality. [15][16][17][18][19] This evaluation of the Pennsylvania Trauma Systems Foundation registry by Morgan et al 5 provides critical data to suggest that PHT in pediatric trauma patients improves mortality. From their 10-year retrospective cohort of more than 14 000 pediatric trauma patients, 559 (4.0%) received a blood product transfusion and 70 (0.5%) received a PHT. As expected, there were significant differences between patients receiving emergency department transfusions (EDT) and PHT. To address potential selection bias, they developed 3:1 propensity