Pediatric traumatic hemorrhagic shock consensus conference recommendations

Expanding beyond trauma: Characterizing low titer group O whole blood (LTOWB) use in children requiring massive transfusion protocol activation

INTRODUCTION

Data regarding low titer group O whole blood (LTOWB) use for hemostatic resuscitation is largely derived from trauma cohorts; studies regarding its use in uninjured pediatric patients are lacking.

METHODS

The blood bank database from a single academic pediatric hospital with a massive transfusion protocol (MTP) allowing the use of LTOWB for any severe bleeding etiology was queried between 2016 and 2023. Pediatric (age <18 years) recipients of LTOWB were included; injured children were excluded. Data recorded included demographics, bleeding etiology, blood volumes, mortality (24-h and in-hospital), organ dysfunction, and, when available, posttransfusion biochemical markers of hemolysis.

RESULTS

Of 112 recipients of LTOWB, 16 met inclusion criteria. Median (IQR) age was 13 years (8-16) and 8/16 (50%) were male. MTP was most often activated on the day of admission (median (IQR) = day 0 (0-1)), and the bleeding etiology was variable, including perioperative (8/16; 50%), gastrointestinal bleed (5/16; 31%), and extracorporeal membrane oxygenation (ECMO) cannulation (3/16; 19%). The median (IQR) weight-adjusted volume of LTOWB transfused was 19 (10-26) mL/kg, and most children (13/16; 81%) received component blood products in addition to LTOWB. The 24-h mortality rate was 25% (4/16) and in-hospital mortality was 44% (7/16). The most common complication was AKI (10/16; 63%). There were no significant differences in biochemical hemolysis markers between group O (n = 7) and non-group O (n = 9) LTOWB recipients at any time point (p = .07-.99).

CONCLUSIONS

LTOWB use was feasible in the resuscitation of children with various bleeding etiologies requiring massive transfusion. Larger prospective investigations are needed to inform guidelines for optimal use in this cohort.

LEVEL OF EVIDENCE

Retrospective Observational Study.

Neonatal trauma resuscitation: Successful use of low-titer O+ whole blood in a 4-day-old infant with hemorrhagic shock

BACKGROUND

Neonatal trauma resuscitation is particularly challenging in cases of profound hemorrhagic shock. Low-titer group O+ whole blood (LTOWB+) has emerged as a potentially effective option in pediatric trauma, but its use in neonates is debated due to risks such as D-alloimmunization. In life-threatening emergencies, decisions must carefully balance immediate survival benefits against long-term risks.

STUDY DESIGN AND METHODS

We present a case report of a 4-day-old neonate transported as a Level 1 trauma following a dog attack to the head, resulting in hemorrhagic shock and cardiac arrest. Upon arrival to the trauma bay, the patient was pulseless, with unsuccessful intraosseous and intravenous vascular access attempts. Access was eventually achieved using an umbilical venous catheter, enabling administration of LTOWB+.

RESULTS

Administration of LTOWB+ resulted in the return of spontaneous circulation, improved perfusion, and hemodynamic stabilization. The patient remained alive at the 6-month follow-up. LTOWB+ facilitated rapid correction of hemorrhagic shock with no immediate complications observed.

DISCUSSION

This case underscores the challenges of neonatal trauma resuscitation, including vascular access and the use of LTOWB+. LTOWB+ proved lifesaving, enabling rapid correction of acidosis and an improved outcome. Although concerns persist regarding LTOWB+ administration, the immediate survival benefits outweigh the risks, supported by evidence demonstrating its efficacy and safety. This case highlights the need for adaptability and a systematic approach to managing complex neonatal trauma scenarios. We argue that LTOWB+ is poised to become a pillar of pediatric resuscitation, providing a lifesaving, efficient, and safe option even in the newborn.

Optimizing Pediatric Resuscitation: Evidence-Based Approaches and Emerging Trends

Pediatric hemorrhagic shock is a life-threatening condition associated with significant morbidity and mortality. While extensive literature guides resuscitation practices in adults, evidence for pediatric patients is evolving. The management of hemorrhagic shock in children is further complicated by their anatomic and physiologic differences, which limit the applicability of adult-derived protocols. This review focuses on the management of pediatric hemorrhagic shock with an emphasis on identification of shock, vascular access, transfusion strategies, and the use of resuscitative adjuncts. In order to improve outcomes, a coordinated effort is needed to develop evidence-based, pediatric-specific guidelines and ensure universal preparedness to manage exsanguinating children.

Forty-eight-hour cold-stored whole blood in paediatric cardiac surgery: Implications for haemostasis and blood donor exposures

BACKGROUND AND OBJECTIVES

Cold-stored whole blood (CS-WB) in paediatric cardiac surgery is making a resurgence, given its identified benefits compared to conventional blood component therapy (CT).

STUDY DESIGN AND METHODS

A single-centre retrospective study was conducted from January 2018 to October 2018 by including children <18 years of age undergoing cardiac surgery requiring cardiopulmonary bypass. ABO-compatible CS-WB from non-directed random donors was leukoreduced with platelet-sparing filters and compared with CT.

RESULTS

Fifty-seven patients (30, 53% CS-WB; 27, 47% CT) were studied. Patient demographics were similar, although CT patients were cooled to a lower intra-operative temperature. Blood product requirements 24 h post operation were less in the CS-WB group (11.1 vs. 26.7 mL/kg, p = 0.048). Twelve (40%) patients in the CS-WB cohort had more than one donor exposure versus 25 (93%) in the CT group (p < 0.001). CT patients compared to CS-WB patients had a greater decrease in pre-operative versus 48-h post-operative haemoglobin, platelets and prothrombin time. Patients who received CT compared to CS-WB had a trend towards higher median (interquartile range [IQR]) chest-tube output (mL/kg/h) in the first 4 h post cardiac intensive care unit (ICU) admission (2.1 [0.8, 3] vs. 1.6 [0.8, 2.2], p = 0.197). There was no difference in antifibrinolytic use, length of stay, sepsis, acute kidney injury or wound infection. Survival to discharge was similar.

CONCLUSION

CS-WB in paediatric cardiac surgery may reduce donor exposure and improve haemostatic balance. Future multi-centre prospective studies are needed to validate these findings and identify patients who would benefit from CS-WB in paediatric cardiac surgery.

Pre-hospital Tourniquet Use in Adolescent and Pediatric Traumatic Hemorrhage: A National Study

BACKGROUND

Tourniquet placement (TP) is a crucial intervention to control hemorrhage, but limited literature exists for use in children. This study aimed to evaluate the effectiveness of tourniquet application by different providers (Emergency Medical Services (EMS), first responder (FR), and bystanders), hypothesizing equivalent impact on outcomes for pediatric trauma patients for all providers.

METHODS

Data from the National EMS Information Systems (NEMSIS) 2017-2020 was used to examine patients 0-19 years old and assess the outcomes of tourniquet application. We considered demographics, procedure success, timing of TP relative to EMS arrival, revised trauma score (RTS), and improvement in acuity. Multivariable logistic regression models were employed to predict initial acuity and likelihood of acuity improvement after TP, while accounting for patient and provider-related variables.

RESULTS

301 patients were included with a median age of 17 and 86.7 % male. TP by any provider before EMS transport arrival was associated with reduced odds of critical acuity upon EMS arrival (OR = 0.84, CI = 0.76-0.94, p = 0.003). After EMS arrival, bystander- and FR-placed tourniquets were associated with increased odds of improved acuity compared to EMS-placed tourniquets (OR = 1.90, CI = 1.06-3.41, p = 0.03). There was only one TP failure (0.43 %) in the EMS group. TP failure was associated with decreased odds of acuity improvement (OR = 0.62, CI = 0.44-0.86, p = 0.005).

CONCLUSION

Early TP for pediatric traumatic hemorrhage is crucial. Failures were rare. Placement by bystanders and FR were associated with improved acuity when controlling for other factors including RTS and EMS arrival time. These findings emphasize the importance of training on TP for all providers in prehospital settings.

LEVEL OF EVIDENCE

IV.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

OBJECTIVES

Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021.

METHODS

We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.

RESULTS

We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%).

CONCLUSIONS

This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Survey of pediatric massive transfusion protocol practice at United States level I trauma centers: An AABB Pediatric Transfusion Medicine Subsection study

BACKGROUND

Trauma remains the leading cause of pediatric mortality in the United States. Although use of massive transfusion protocols (MTPs) in this population is widespread, optimal pediatric resuscitation is not well established. We sought to assess contemporary pediatric MTP practice in the United States.

STUDY DESIGN AND METHODS

A web-based survey was designed by the Association for the Advancement of Blood & Biotherapies (AABB) Pediatric Transfusion Medicine Subsection and distributed to select American College of Surgeons (ACS) Level I Verified pediatric trauma centers. The survey assessed current MTP policy, implementation, and recent changes in practice.

RESULTS

Response rate was 55% (22/40). Almost half of the respondents were from the South. The median RBC:plasma ratio was 1 (interquartile range 1-1.5). Protocolized fibrinogen supplementation was common while integration of antifibrinolytic therapy into MTPs was infrequent. Viscoelastic testing (VET) was available at most sites, 71% (15/21, one site did not respond), and was generally utilized on an ad-hoc basis. Roughly, a third of sites had changed their MTP in the past 3 years due to blood supply issues, and about a third reported having group O Whole Blood on-site.

CONCLUSION

MTP practice is similar throughout the United States. Though fibrinogen supplementation is common-other emerging interventions such as antifibrinolytic therapy or utilization of routine viscoelastic testing-are not widespread. Pediatric transfusion medicine experts must continue to follow practice change, as contemporary large trials begin to characterize new supportive modalities to optimize resuscitation in pediatric trauma patients.

A nomogram for predicting hemorrhagic shock in pediatric patients with multiple trauma

The timely detection and management of hemorrhagic shock hold paramount importance in clinical practice. This study was designed to establish a nomogram that may facilitate early identification of hemorrhagic shock in pediatric patients with multiple-trauma. A retrospective study was conducted utilizing a cohort comprising 325 pediatric patients diagnosed with multiple-trauma, who received treatment at the Children's Hospital, Zhejiang University School of Medicine, Zhejiang, China. For external validation, an additional cohort of 144 patients from a children's hospital in Taizhou was included. The model's predictor selection was optimized through the application of the Least Absolute  Shrinkage and Selection Operator (LASSO) regression. Subsequently, a prediction nomogram was constructed using multivariable logistic regression analysis. The performance and clinical utility of the developed model were comprehensively assessed utilizing various statistical metrics, including Harrell's Concordance Index (C-index), receiver operating characteristic (ROC) curve analysis, calibration curve analysis, and decision curve analysis (DCA). Multivariate logistic regression analysis identified systolic blood pressure (ΔSBP), platelet count, activated partial thromboplastin time (APTT), and injury severity score (ISS) as independent predictors for hemorrhagic shock. The nomogram constructed using these predictors demonstrated robust predictive capabilities, as evidenced by an impressive area under the curve (AUC) value of 0.963. The model's goodness-of-fit was assessed using the Hosmer-Lemeshow test (χ2 = 10.023, P = 0.209). Furthermore, decision curve analysis revealed significantly improved net benefits with the model. External validation further confirmed the reliability of the proposed predictive nomogram. This study successfully developed a nomogram for predicting the occurrence of hemorrhagic shock in pediatric patients with multiple trauma. This nomogram may serve as an accurate and effective tool for timely and efficient management of children with multiple trauma.

Polytrauma in Children—Epidemiology, Acute Diagnostic Evaluation, and Treatment

BACKGROUND

Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room.

METHODS

This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered.

RESULTS

Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial.

CONCLUSION

4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

Increased platelet to red blood cell transfusion ratio associated with acute kidney injury in children with life-threatening bleeding

INTRODUCTION

Transfusion may increase the risk of organ failure through immunomodulatory effects. The primary objective of this study was to assess for patient or transfusion-related factors that are independently associated with the risk of acute kidney injury (AKI) and acute respiratory distress syndrome (ARDS) in a cohort of children with life-threatening bleeding from all etiologies.

METHODS

In a secondary analysis of the prospective observational massive transfusion in children (MATIC) study, multivariable logistic regression was performed in an adjusted analysis to determine if blood product ratios or deficits were independently associated with AKI or ARDS in children with life-threatening bleeding.

RESULTS

There were 449 children included with a median (interquartile range, IQR) age of 7.3 years (1.7-14.7). Within 5 days of the life-threatening bleeding event, AKI occurred in 18.5% and ARDS occurred in 20.3% of the subjects. Every 10% increase in the platelet to red blood cell transfusion ratio is independently associated with a 12.7% increase in the odds of AKI (adjusted odds ratio 1.127; 95% confidence interval 1.025-1.239; p-value .013). Subjects with operative or medical etiologies were independently associated with an increased risk of AKI compared to those with traumatic injury. No transfusion-related variables were independently associated with the risk of developing ARDS.

CONCLUSION

The use of increased platelet to red blood cell transfusion ratios in children with life-threatening bleeding of any etiology may increase the risk of AKI but not ARDS. Prospective trials are needed to determine if increased platelet use in this cohort increases the risk of AKI to examine possible mechanisms.

Massive transfusion in trauma

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of currently recommended treatment approaches for traumatic hemorrhage shock, with a special focus on massive transfusion.

RECENT FINDINGS

Severe trauma patients require massive transfusion, but consensual international definitions for traumatic hemorrhage shock and massive transfusion are missing. Current literature defines a massive transfusion as transfusion of a minimum of 3-4 packed red blood cells within 1 h. Using standard laboratory and/or viscoelastic tests, earliest diagnosis and treatment should focus on trauma-induced coagulopathy and substitution of substantiated deficiencies.

SUMMARY

To initiate therapy immediately massive transfusion protocols are helpful focusing on early hemorrhage control using hemostatic dressing and tourniquets, correction of metabolic derangements to decrease coagulopathy and substitution according to viscoelastic assays and blood gases analysis with tranexamic acid, fibrinogen concentrate, red blood cells, plasma and platelets are recommended. Alternatively, the use of whole blood is possible. If needed, further support using prothrombin complex, factor XIII or desmopressin is suggested.

Use of whole blood in pediatric trauma: a narrative review

Balanced hemostatic resuscitation has been associated with improved outcomes in patients with both pediatric and adult trauma. Cold-stored, low-titer group O whole blood (LTOWB) has been increasingly used as a primary resuscitation product in trauma in recent years. Benefits of LTOWB include rapid, balanced resuscitation in one product, platelets stored at 4°C, fewer additives and fewer donor exposures. The major theoretical risk of LTOWB transfusion is hemolysis, however this has not been shown in the literature. LTOWB use in injured pediatric populations is increasing but is not yet widespread. Seven studies to date have described the use of LTOWB in pediatric trauma cohorts. Safety of LTOWB use in both group O and non-group O pediatric patients has been shown in several studies, as indicated by the absence of hemolysis and acute transfusion reactions, and comparable risk of organ failure. Reported benefits of LTOWB included faster resolution of shock and coagulopathy, lower volumes of transfused blood products, and an independent association with increased survival in massively transfused patients. Overall, pediatric data are limited by small sample sizes and mostly single center cohorts. Multicenter randomized controlled trials are needed.

A scoping review of two decades of pediatric humanitarian care during wartime

ABSTRACT

Humanitarian care is a vital component of the wartime mission. Children comprise a significant proportion of casualties injured by explosives and penetrating weapons. Children face a variety of unique injury patterns in the combat setting as high-powered firearms and explosives are rarely seen in the civilian setting. We sought to perform a scoping review of pediatric research from the recent US-led wars in Afghanistan, and Iraq conflicts beginning in 2001. We used Google Scholar and PubMed to identify pediatric combat literature published between 2001 and 2022. We utilized the PRISMA-ScR Checklist to conduct this review. We identified 52 studies that met inclusion for this analysis-1 prospective observational study, 50 retrospective studies, and 1 case report. All the original research studies were retrospective in nature except for one. We identified one prospective study that was a post hoc subanalysis from an overall study assessing the success of prehospital lifesaving interventions. Most of the articles came from varying registries created by the United States and British militaries for the purposes of trauma performance improvement. The deployed health service support mission often includes treatment of pediatric trauma patients. The deployed health service support mission often includes treatment of pediatric trauma patients. We found that available literature from this setting is limited to retrospective studies except for one prospective study. Our findings suggest that pediatric humanitarian care was a significant source of medical resource consumption within both of the major wars. Further, many of the lessons learned have directly translated into changes in civilian pediatric trauma care practices highlighting the need for collaborative scientific developments between the military and civilian trauma programs.

LEVEL OF EVIDENCE

Systematic Review/Meta-Analyses; Level III.

Pediatric traumatic hemorrhagic shock consensus conference research priorities

BACKGROUND

Traumatic injury is the leading cause of death in children and adolescents. Hemorrhagic shock remains a common and preventable cause of death in the pediatric trauma patients. A paucity of high-quality evidence is available to guide specific aspects of hemorrhage control in this population. We sought to identify high-priority research topics for the care of pediatric trauma patients in hemorrhagic shock.

METHODS

A panel of 16 consensus multidisciplinary committee members from the Pediatric Traumatic Hemorrhagic Shock Consensus Conference developed research priorities for addressing knowledge gaps in the care of injured children and adolescents in hemorrhagic shock. These ideas were informed by a systematic review of topics in this area and a discussion of these areas in the consensus conference. Research priorities were synthesized along themes and prioritized by anonymous voting.

RESULTS

Eleven research priorities that warrant additional investigation were identified by the consensus committee. Areas of proposed study included well-designed clinical trials and evaluations, including increasing the speed and accuracy of identifying and treating hemorrhagic shock, defining the role of whole blood and tranexamic acid use, and assessment of the utility and appropriate use of viscoelastic techniques during early resuscitation. The committee recommended the need to standardize essential definitions, data elements, and data collection to facilitate research in this area.

CONCLUSION

Research gaps remain in many areas related to the care of hemorrhagic shock after pediatric injury. Addressing these gaps is needed to develop improved evidence-based recommendations for the care of pediatric trauma patients in hemorrhagic shock.