Brought to you by the EAST Manuscript and Literature Review Committee
This issue was prepared by EAST Member Raphael Parrado, MD, MS andPediatric Trauma SocietyMembers Michael Rempel, DNP, RN, CNOR and Richard J. Scriven, MD.
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Hemorrhagic Shock remains one of the largest culprits in early mortality in pediatric trauma. This study continues the analysis and further search for the best practices for hemostatic resuscitation. Research continues to develop, and the use of low-titer-group O whole blood (LTOWB) in adult trauma is increasing. The potential benefits of using LTWOB over traditional component therapy include increased theoretical efficacy for oxygen delivery and hemostasis due to using fewer anticoagulants and additives, reduced time to transfusion, and potentially improved hemostasis as platelets (PLT) need cold storage. On the other hand, there has been a concern for hemolysis and the risk of RhD alloimmunization in younger patients. Currently, multiple observational studies have shown efficacy and safety with the use of LTOWB. Furthermore, there has been data on the “dose-response” effect of whole blood (WB) to total transfusion volume (TTV) or WB/TTV ratio. This study aims to provide a national view of the relationship between the WB/TTV ratio and mortality in children with a focus on massive transfusion situations and children less than 14 years old.
The investigators used the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database from 2020 to 2021. They included patients younger than 18 who received any red blood cell (RB) or WB transfusion within the first 4 hours of arrival. Patients who died within 80 minutes of arrival, were transferred to another center within 24 hours of injury, and had a mechanism of injury different from blunt or penetrating or missing data were excluded from the analysis. The primary outcome was 24-hour mortality, and the secondary outcome was 4-hour mortality. The ratio was obtained by dividing the volume of WB in milliliters by the sum of WB, RBC, FFP, and PLT. Pediatric Shock was defined by the Pediatric age-adjusted shock index.
Over the study period, 4323 patients were included. 88% (3786) received component therapy only (CT), and 12% (537) received WB with or without CT. Patients in the WB group were significantly older (16 vs. 15 years), male predominant (77% vs. 70%), more likely to sustain penetrating trauma (49% vs. 43%), had higher injury severity scores (26 vs. 25) and were more often in Shock (70.5% vs 60.4%). The median volume of WB administered in the first 4 hours was 13 (7-21) ml/kg. The TTV was significantly higher in the WB group (26 vs. 19 ml/kg). However, less of each component was used in resuscitation. After adjusting for potential confounders, WB transfusion was significantly associated with lower odds of 4 hours (OR 0.58) and 24-hour mortality (OR 0.46). The median WB/TTV ratio from the first 4 hours was 50%. After multivariate analysis, there was a 9% decrease in adjusted odds of mortality for each 10% increase in the WB/TTV ratio. Massive transfusion was used in 1173 patients. WB transfusion was associated with a significant decrease in the 24-hour mortality (OR 0.43) but not in the 4 hours; there was no statistical difference in the WB/TTV ratio. Finally, in patients 14 years or younger (1903), there was a decrease in 24-hour mortality with any WB transfusion (OR 0.47) and a 15% decrease in 24-hour mortality odds for every 10% increase in the WB/TTV ratio.
This study provides a larger take on using WB in pediatric hemostatic resuscitation. There is a notable decrease in 24-hour mortality when whole blood is used as part of the resuscitation. Notably, with more increased proportional use of WB, there is an increased decrease in mortality. As previously discussed, the benefit might be faster and easier achieving balanced resuscitation and a higher concentration of factors in WB. Moreover, there was a benefit in patients younger than 14 years old, with a reduction in mortality in the first 24 hours. The most notable limitation is the retrospective observational design and the difference in practices among centers, which can be mitigated by multivariate analysis and clustering of centers. Also, there is a limitation on the dataset that provides transfusion volumes for the first hours. Overall, this study provides a national view of the potential benefits of the use of WB in pediatric resuscitation, even as a part of total resuscitation. Nowadays, WB remains a limited resource in pediatric centers, but this is a call for further investigation to determine optimal resuscitation practices and improve outcomes in this patient population.
Anderson and colleagues conducted a retrospective study to evaluate the effectiveness and efficiency of trauma team activation (TTA) protocols within a multi-hospital healthcare system. The researchers reviewed data from over 40,000 adult trauma patients, examining the relationship between trauma activation status, injury severity, and clinical outcomes such as mortality, ICU admissions, and emergent procedures. Their analysis revealed that a significant proportion of patients who received full trauma team activation had only minor injuries and did not require critical interventions. Conversely, some patients with severe injuries who did not receive TTA experienced worse outcomes, pointing to both overtriage and undertriage as ongoing concerns in trauma systems. The findings suggest that physiologic indicators such as low Glasgow Coma Scale scores and hypotension were more predictive of the need for trauma team activation than mechanism of injury alone.
The authors concluded that existing TTA protocols could be refined to better allocate resources and reduce unnecessary team mobilizations without compromising patient care. They recommend consideration of a tiered trauma activation system that prioritizes clinical judgment and physiological criteria over broad mechanism-based triggers. This study aligns with themes present in several EAST Practice Management Guidelines, particularly those addressing trauma triage, geriatric trauma evaluation, and resource optimization. While not tied to a single PMG, the findings support EAST's emphasis on evidence-based strategies to enhance trauma system performance. Anderson et al.’s work contributes valuable insight into the development of more efficient and targeted trauma response models, helping inform future guideline revisions and institutional quality improvement efforts.
This study examines the trends of injury seen in children from a relatively new mode of transportation, the electrical bike (E-bike) and power scooter (P-scooter). These E-devices have become much more popular in the last 20 years as battery technology has allowed riders to go faster and longer periods of time between charging. Many localities classify these devices as bicycles and not motorized vehicles. This exempts the rider from licensing and mandatory safety equipment.
The investigators conducted a retrospective cohort study of patients less than 18, between the years 2018-2023 who sustained injuries from E-bikes and P-scooters. The severity of injury was rated either by injury severity score (ISS) of greater then 15, need for ICU admission, direct transfer to the operating room, acute interventions performed in the trauma room and in hospital death.
1466 patients were included in their study, 216 (14.7%) were hospitalized, a median age of 14.0, and male predominance (69%). Shockingly the number of ED visits increased 3.5-fold from the beginning to the end of the study. The study group includes 3 patients (1.4%) who died and 9 (4.1%) who required rehabilitation care. The authors conclude that current personal and road safety regulations are inadequate and require revision and stricter enforcement. I would go further to advocate for better education for the children and their parents. We are seeing children as young as 6 years of age who are riding these devices, often unhelmeted, and arriving at our pediatric trauma center with serious injuries. The use of these devices is increasing every year, so we will be seeing more and more of these patients. The parents need to know that although these may look like a simple scooters they are powerful motorized vehicles and can inflict serious injury on their children.
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This Literature Review is being brought to you by the EAST Manuscript and Literature Review Committee. Have a suggestion for a review or an additional comment on articles reviewed? Please email [email protected]. Previous issues available on the EAST website.
