Concise Critical Appraisal: Prehospital Transfusions and Mortality in Pediatric Trauma

Hemorrhagic shock is a common cause of death in children who have sustained trauma and frequently leads to poor outcomes. Prehospital fluid replacement and management is considered an important therapy. In the adult trauma literature, there is increasing evidence that early resuscitation with blood products, as opposed to crystalloid, improves outcomes.¹ This has been suggested in pediatric literature as well,² although the data have primarily been from small single-center studies. The Pediatric Traumatic Hemorrhagic Shock Consensus Conference addressed the paucity of data and proposed research priorities, including the improvement of recognition and treatment of hemorrhagic shock in children.³

A recent study by Morgan et al aligns with this goal of improving pediatric hemorrhagic shock recognition and treatment by reviewing a statewide trauma database to determine the association between prehospital transfusion and outcomes in pediatric trauma.⁴ The authors performed a retrospective review of the Pennsylvania Trauma Systems Foundation registry, which includes data from more than 50 trauma centers in the state.⁴ They queried the registry for children with trauma between ages 0 and 17 years who received a red blood cell transfusion either in the emergency department (EDT) or in the prehospital setting (PHT) between January 2009 and December 2019. Burn patients and interfacility transfers were excluded because they were more likely to have been fluid resuscitated and stabilized.

Data collected included demographics, injury severity score (ISS), ventilator days, hospital and pediatric ICU length of stay, mortality, transfusion status, injury mechanism, and transport information. The primary outcome was the association between prehospital transfusion and 24-hour mortality. Secondary outcomes included the association between prehospital transfusion and in-hospital mortality as well as in-hospital complications (e.g., sepsis, acute kidney injury). Propensity score matching was used to address selection bias, and a mixed-effects logistic regression model that was adjusted for sex, ISS, and insurance status was also constructed.

Of the 559 children selected, 70 (13%) were in the PHT group and 489 (87%) in the EDT group. Before propensity scoring, the PHT group was shown to have higher rates of shock and blunt versus penetrating injury, were more often identified as White versus non-White ethnicities, and were more often transported by helicopter emergency medical services compared to ambulance. After propensity matching, the authors reported a cohort of 207 children, with 68 in the PHT group and 139 in the EDT group. In this cohort, 24-hour mortality was lower in the PHT group compared to the EDT group (16% vs. 27%). In-hospital mortality was also lower in the PHT group compared to the EDT group (21% vs. 32%). After mixed-effects logistic modeling, the authors demonstrated the reduced odds of 24-hour and in-hospital mortality in the PHT group compared with the EDT group. Finally, the authors determined that the number needed to treat with PHT to reduce 24-hour mortality was 6 (95% CI, 3-10) and for in-hospital mortality was 5 (95% CI, 3.2-9.7).

The authors found that children who sustained trauma were likely to benefit from early hemostatic resuscitation with blood transfusion, which is consistent with other studies. Although it represents the largest cohort to date on PHT, the authors acknowledge that the small sample size is a limitation of this study. In addition, shock can be challenging to diagnose in children, particularly for medical professionals who primarily treat adults, because of the physiologic compensatory mechanisms that maintain normal blood pressure in children and the differences in vital signs among ages. Moreover, hemorrhagic shock in pediatrics is relatively rare. However, given the growing body of evidence suggesting that early resuscitation with blood products compared to crystalloid is associated with improved outcomes, these challenges should be addressed with education and training so that appropriate resuscitation can take place at the appropriate time.

References

1. Guyette FX, Sperry JL, Peitzman AB, et al. Prehospital blood product and crystalloid resuscitation in the severely injured patient: a secondary analysis of the Prehospital Air Medical Plasma Trial. Ann Surg. 2021 Feb 1;273(2):358-364.
2. Hussmann B, Lefering R, Kauther MD, et al. Influence of prehospital volume replacement on outcome in polytraumatized children. Crit Care. 2012 Oct 18;16(5):R201.
3. Russell RT, Esparaz JR, Beckwith MA, et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10.
4. Morgan KM, Abou-Khalil A, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of prehospital transfusion with mortality in pediatric trauma. JAMA Pediatr. 2023 Jul 1;177(7):693-699.