Prehospital blood transfusion in pediatric trauma
Myron Yaster MD, Justin L. Lockman MD MSEd, Shawn Jackson MD
When I first arrived in Maryland as an attending anesthesiologist and pediatric intensivist at the Johns Hopkins Hospital in 1982, I was introduced to the world-famous Maryland Shock Trauma system and its leaders Dr. R. Adams Cowley (adults) and Dr. J. Alex Haller (pediatrics). They pioneered the concept of the “golden hour” and the vital importance of an integrated trauma hospital as a cornerstone of Maryland's EMS Trauma System. Shock Trauma became a model for the country. What is a bit less known is that the pediatric piece of Shock Trauma was the Johns Hopkins Children’s Medical and Surgical Center. I and my colleagues, Drs. David Nichols, Jay Deshpande, Randal Wetzel, Ivor Berkowitz, Hal Shaffner, and Jim Buck to name a few, became integral members of the system and provided training to EMS personnel. Hence my continuing interest in pediatric trauma and delight in highlighting articles on this subject.
In today’s PAAD, we review an article by Morgan et al.(1) who report on the use of prehospital blood transfusion in hemorrhagic pediatric trauma patients. I’ve asked the PAAD’s lead ICU editor Dr. Justin Lockman (of CHOP) and Dr. Shawn Jackson of Harvard’s Boston Children’s Hospital to assist. Myron Yaster MD
Incidentally, Shawn is one of several fellows and faculty who are leading an effort to revitalize and restart the Society for Pediatric Anesthesia’s special interest group of combined pediatric anesthesia and critical care specialists. If you are board certified in pediatrics, anesthesiology, pediatric critical care and pediatric anesthesiology – or are in the process of training along this pathway – and are interested in joining this special interest group please contact either:
Shawn (Shawn.Jackson@childrens.harvard.edu);
Branden Engorn (Rady Children's) engornb@gmail.com;
Tim Welch (Omaha) twelch@childrensomaha.org;
Ethan Sanford (UT Southwestern) ethan.sanford@utsouthwestern.edu;
Andrew Renuart (Boston) Andrew.Renuart@childrens.harvard.edu
Original article
Katrina M Morgan, Elissa Abou-Khalil, Stephen Strotmeyer, Ward M Richardson, Barbara A Gaines, Christine M Leeper. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr. 2023 May 22;e231291. doi: 10.1001/jamapediatrics.2023.1291. PMID: 37213096
“Hemorrhagic shock is one of the most common causes of preventable mortality in injured children.”(1,2) As you all know, tachycardia may be the first, and sometimes only sign of shock in children. Because of their ability to “compensate” with increased heart rate and increased systemic vascular resistance (think: “delayed capillary refill”), hypotension often occurs only later in hemorrhagic shock after approximately 30-45% of blood volume has been lost (ATLS). Traditionally, early resuscitation guidance involved 20 mL/kg (or more!) of balanced salt solutions prior to blood transfusion, including for several pediatric prehospital protocols.(3) On the other hand, “there is increasing adult studies showing restrictive prehospital crystalloid and early balanced blood product resuscitation in combat and civilian trauma improves outcomes. Therefore, resuscitation practices are shifting away from crystalloid and toward initial resuscitation with blood products in injured adult patients.”(1,4,5)
“Current literature suggests children in hemorrhagic shock benefit from fewer crystalloid boluses to prevent the deleterious effects of dilution and volume overload.”(1) This makes sense to us, because (after all) children don’t bleed crystalloid, they bleed blood! While several publications have described pediatric prehospital blood transfusion, there have been little to no demonstrated outcome difference. In today’s PAAD, the authors studied whether “prehospital transfusion would be associated with lower rates of mortality compared with transfusion on arrival to the emergency department?”(1) The answer was YES, “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.”(1)
The logistics of providing blood in prehospital resuscitation is, as the authors point out, complex to say the least. So are the logistics of prehospital randomized controlled trials. For the former, how to even establish IV (or IO) access in the field is only the first part of the problem. How to store and have blood products available without wastage during transport is another. Should whole blood or component blood products (plasma, platelets, packed red blood cells) be used, and at what ratio? How would we ensure proper storage, preparation, etc. in the field?
Regarding research studies, there are often questions of consent (which CAN be waived for this type of study, just ask your local IRB about it) as well as logistics of randomization in the field and in the moment. Not to mention: would EMS providers have equipoise on this issue? Can anyone imagine having a cooler with blood in the ambulance and not using it? But all of these issues are surmountable, and we hope that SPA members will take the initiative to really do these types of studies. If not us, then who?
Does your prehospital system have these capabilities? Do you or members of your department interact with EMS in training and establishing treatment protocols? Would you like to join other SPA members to study this and other trauma-related issues? These are issues that may be of great interest particularly to our dual-traind peds anesthesia/picu members (and please don’t forget to email Shawn – see above). What are your thoughts? Send them to Myron and he will publish in the Friday Reader response.
References
1. Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA pediatrics 2023.
2. West BA, Rudd RA, Sauber-Schatz EK, Ballesteros MF. Unintentional injury deaths in children and youth, 2010–2019. Journal of Safety Research 2021;78:322-30.
3. Fahy AS, Thiels CA, Polites SF, Parker M, Ishitani MB, Moir CR, Berns K, Stubbs JR, Jenkins DH, Zietlow SP, Zielinski MD. Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes. Pediatr Surg Int 2017;33:787-92.
4. Powell EK, Hinckley WR, Gottula A, Hart KW, Lindsell CJ, McMullan JT. Shorter times to packed red blood cell transfusion are associated with decreased risk of death in traumatically injured patients. J Trauma Acute Care Surg 2016;81:458-62.
5. Sheppard FR, Schaub LJ, Cap COLAP, Macko AR, Moore HB, Moore EE, Glaser CDRJJ. Whole blood mitigates the acute coagulopathy of trauma and avoids the coagulopathy of crystalloid resuscitation. Journal of Trauma and Acute Care Surgery 2018;85.