The Efficacy of Low-Titer Group O Whole Blood Compared With Component Therapy in Civilian Trauma Patients: A Meta-Analysis.

OBJECTIVES: To assess if transfusion with low-titer group O whole blood (LTOWB) is associated with improved early and/or late survival compared with component blood product therapy (CT) in bleeding trauma patients. DATA SOURCES: A systematic search of PubMed, CINAHL, and Web of Science was performed from their inception through December 1, 2023. Key terms included injury, hemorrhage, bleeding, blood transfusion, and whole blood. STUDY SELECTION: All studies comparing outcomes in injured civilian adults and children who received LTOWB versus CT were included. DATA EXTRACTION: Data including author, publication year, sample size, total blood volumes, and clinical outcomes were extracted from each article and reported following the Meta-analysis Of Observational Studies in Epidemiology guidelines. Main outcomes were 24-hour (early) and combined 28-day, 30-day, and in-hospital (late) mortality rates between recipients of LTOWB versus CT, which were pooled using random-effects models. DATA SYNTHESIS: Of 1297 studies reviewed, 24 were appropriate for analysis. Total subjects numbered 58,717 of whom 5,164 received LTOWB. Eleven studies included adults-only, seven included both adults and adolescents, and six only included children. The median (interquartile range) age for patients who received LTOWB and CT was 35 years (24-39) and 35.5 years (23-39), respectively. Overall, 14 studies reported early mortality and 22 studies reported late mortality. LTOWB was associated with improved 24-hour survival (risk ratios [RRs] [95% CI] = 1.07 [1.03-1.12]) and late (RR [95% CI] = 1.05 [1.01-1.09]) survival compared with component therapy. There was no evidence of small study bias and all studies were graded as a moderate level of bias. CONCLUSIONS: These data suggest hemostatic resuscitation with LTOWB compared with CT improves early and late survival outcomes in bleeding civilian trauma patients. The majority of subjects were injured adults; multicenter randomized controlled studies in injured adults and children are underway to confirm these findings.

New Functional Impairment After Hospital Discharge by Traumatic Brain Injury Mechanism in Younger Than 3 Years Old Admitted to the PICU in a Single Center Retrospective Study.

OBJECTIVES: Children who suffer traumatic brain injury (TBI) are at high risk of morbidity and mortality. We hypothesized that in patients with TBI, the abusive head trauma (AHT) mechanism vs. accidental TBI (aTBI) would be associated with higher frequency of new functional impairment between baseline and later follow-up. DESIGN: Retrospective single center cohort study. SETTING AND PATIENTS: Children younger than 3 years old admitted with TBI to the PICU at a level 1 trauma center between 2014 and 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, TBI mechanism, and Functional Status Scale (FSS) scores at baseline, hospital discharge, short-term (median, 10 mo [interquartile range 3-12 mo]), and long-term (median, 4 yr [3-6 yr]) postdischarge were abstracted from the electronic health record. New impairment was defined as an increase in FSS greater than 1 from baseline. Patients who died were assigned the highest score (30). Multivariable logistic regression was performed to determine the association between TBI mechanism with new impairment. Over 6 years, there were 460 TBI children (170 AHT, 290 aTBI), of which 13 with AHT and four with aTBI died. Frequency of new impairment by follow-up interval, in AHT vs. aTBI patients, were as follows: hospital discharge (42/157 [27%] vs. 27/286 [9%]; p < 0.001), short-term (42/153 [27%] vs. 26/259 [10%]; p < 0.001), and long-term (32/114 [28%] vs. 18/178 [10%]; p < 0.001). Sensory, communication, and motor domains were worse in AHT patients at the short- and long-term timepoint. On multivariable analysis, AHT mechanism was associated with greater odds (odds ratio [95% CI]) of poor outcome (death and new impairment) at hospital discharge (4.4 [2.2-8.9]), short-term (2.7 [1.5-4.9]), and long-term timepoints (2.4 [1.2-4.8]; p < 0.05). CONCLUSIONS: In patients younger than 3 years old admitted to the PICU after TBI, the AHT mechanism-vs. aTBI-is associated with greater odds of poor outcome in the follow-up period through to ~5 years postdischarge. New impairment occurred in multiple domains and only AHT patients further declined in FSS over time.

Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion.

OBJECTIVE: The aim of this study was to assess the survival impact of low-titer group O whole blood (LTOWB) in injured pediatric patients who require massive transfusion. SUMMARY BACKGROUND DATA: Limited data are available regarding the effectiveness of LTOWB in pediatric trauma. METHODS: A prospective observational study of children requiring massive transfusion after injury at UPMC Children's Hospital of Pittsburgh, an urban academic pediatric Level 1 trauma center. Injured children ages 1 to 17 years who received a total of >40 mL/kg of LTOWB and/or conventional components over the 24 hours after admission were included. Patient characteristics, blood product utilization and clinical outcomes were analyzed using Kaplan-Meier survival curves, log rank tests and Cox proportional hazards regression analyses. The primary outcome was 28-day survival. RESULTS: Of patients analyzed, 27 of 80 (33%) received LTOWB as part of their hemostatic resuscitation. The LTOWB group was comparable to the component therapy group on baseline demographic and physiologic parameters except older age, higher body weight, and lower red blood cell and plasma transfusion volumes. After adjusting for age, total blood product volume transfused in 24 hours, admission base deficit, international normalized ratio (INR), and injury severity score (ISS), children who received LTOWB as part of their resuscitation had significantly improved survival at both 72 hours and 28 days post-trauma [adjusted odds ratio (AOR) 0.23, P = 0.009 and AOR 0.41, P = 0.02, respectively]; 6-hour survival was not statistically significant (AOR = 0.51, P = 0.30). Survivors at 28 days in the LTOWB group had reduced hospital LOS, ICU LOS, and ventilator days compared to the CT group. CONCLUSION: Administration of LTOWB during the hemostatic resuscitation of injured children requiring massive transfusion was independently associated with improved 72-hour and 28-day survival.

Receipt of low titer group O whole blood does not lead to hemolysis in children weighing less than 20 kilograms.

OBJECTIVE: The safety of Low Titer Group O Whole Blood (LTOWB) transfusion has not been well-studied in small children. METHODS: This is a single-center retrospective cohort study of pediatric recipients of RhD-LTOWB (June 2016-October 2022) who weigh less than 20 kilograms. Biochemical markers of hemolysis (lactate dehydrogenase, total bilirubin, haptoglobin, and reticulocyte count) and renal function (creatinine and potassium) were recorded on the day of LTOWB transfusion and post-transfusion days 1 and 2. Group O and non-Group O recipients were compared. RESULTS: Twenty-one children were included. Their median (interquartile range [IQR]) weight was 12 kg (12-18) with minimum 2.8 kg, and median (IQR) age was 3 years (1.75-5.00) with minimum 0.08 years (29 days old). The most common indication for transfusion was trauma (17/21; 81%). The median (IQR) volume of LTOWB transfused was 30 mL/kg (20-42). There were 9 non-group O and 12 group O recipients. There were no statistically significant differences in the median concentrations of any of the biochemical markers of hemolysis or the renal function markers between the non-group O and the group O recipients at any of the three time points (p > 0.05 for all comparisons). There were also no statistically significant differences in demographic parameters or clinical outcomes including 28-day mortality, length of stay, ventilator days, and venous thromboembolism between the groups. No transfusion reactions were reported in either group. CONCLUSION: These data suggest LTOWB use is safe in children weighing less than 20 kg. Further multi-center studies and larger cohorts are needed to confirm these results.

Association of Thromboelastography with Progression of Hemorrhagic Injury in Children with Traumatic Brain Injury.

INTRODUCTION: Progression of hemorrhagic injury (PHI) in children with traumatic brain injury portends poor outcomes. The association between thromboelastography (TEG), functional coagulation assays, and PHI is not well characterized in children. METHODS: This was a retrospective cohort study of children presenting with PHI at a pediatric level I academic trauma center from 2015 to 2020. Inclusion criteria were as follows: age less than 18 years, intracranial hemorrhage on admission head computed tomography scan, and admission rapid TEG assay and conventional coagulation tests. PHI was defined by the following radiographic criteria: any expansion of or new intracranial hemorrhage on subsequent head computed tomography scan. Rapid TEG values included Activated Clotting Time (ACT), alpha angle, maximum amplitude, and lysis at 30 min. Wilcoxon rank-sum test was used to assess baseline differences between groups with PHI and without PHI, including laboratory assays. Univariate analysis was performed to examine the association between variables of interest and PHI. Patients were dichotomized on the basis of this cut point to generate a "low ACT" group and a "high ACT" group. These variables were included in a multivariable logistic regression model to determine independent association with traumatic brain injury progression. RESULTS: In total, 219 patients met criteria for analysis. In this cohort, the median (interquartile range [IQR]) age = 6 (2-12) years, median (IQR) Injury Severity Score = 21 (11-27), 68% were boys, and 69% sustained blunt injury. The rate of PHI was 25% (54). Median (IQR) time to PHI was 1 (0-4) days. Children with PHI had a higher Injury Severity Score (p < 0.001), lower Glasgow Coma Scale (p < 0.001), greater incidence of shock (p = 0.04), and lower admission hemoglobin (p = 0.02) compared with those without PHI. Children with PHI had a higher International Normalized Ratio (INR) and longer TEG-ACT; other TEG values (alpha angle, maximum amplitude, and lysis at 30 min) were not associated with PHI. In the logistic regression model accounting for other covariates associated with PHI, elevated ACT remained an independent predictor of progression (odds ratio = 2.25, 95% confidence interval 1.09-4.66; p = 0.03; area under the receiver operating characteristic curve = 0.76). After adjusting for confounders, INR fell out of the model and was not an independent predictor of progression (odds ratio = 1.32, 95% confidence interval 0.60-2.93; p = 0.49). CONCLUSIONS: Although INR was elevated in children with PHI and has been associated with poor clinical outcomes, only admission TEG-ACT was independently associated with PHI. Further study is warranted to determine whether TEG-ACT reflects an actionable therapeutic target.

Multiorgan Dysfunction Syndrome in Abusive and Accidental Pediatric Traumatic Brain Injury.

BACKGROUND: Abusive head trauma (AHT) is a mechanism of pediatric traumatic brain injury (TBI) with high morbidity and mortality. Multiorgan dysfunction syndrome (MODS), defined as organ dysfunction in two or more organ systems, is also associated with morbidity and mortality in critically ill children. Our objective was to compare the frequency of MODS and evaluate its association with outcome between AHT and accidental TBI (aTBI). METHODS: This was a single center, retrospective cohort study including children under 3 years old admitted to the pediatric intensive care unit with nonpenetrating TBI between 2014 and 2021. Presence or absence of MODS on days 1, 3, and 7 using the Pediatric Logistic Organ Dysfunction-2 score and new impairment status (Functional Status Scale score change > 1 compared with preinjury) at hospital discharge (HD), short-term timepoint, and long-term timepoint were abstracted from the electronic health record. Multiple logistic regression was performed to examine the association between MODS and TBI mechanism with new impairment status. RESULTS: Among 576 children, 215 (37%) had AHT and 361 (63%) had aTBI. More children with AHT had MODS on days 1 (34% vs. 23%, p = 0.003), 3 (28% vs. 6%, p < 0.001), and 7 (17% vs. 3%, p < 0.001) compared with those with aTBI. The most common organ failures were cardiovascular ([AHT] 66% vs. [aTBI] 66%, p = 0.997), neurologic (33% vs. 16%, p < 0.001), and respiratory (34% vs. 15%, p < 0.001). MODS was associated with new impairment in multivariable logistic regression at HD (odds ratio 19.1 [95% confidence interval 9.8-38.6, p < 0.001]), short-term discharge (7.4 [3.7-15.2, p < 0.001]), and long-term discharge (4.3 [2.0-9.4, p < 0.001])]. AHT was also associated with new impairment at HD (3.4 [1.6-7.3, p = 0.001]), short-term discharge (2.5 [1.3-4.7, p = 0.005]), and long-term discharge (2.1 [1.1-4.1, p = 0.036]). CONCLUSIONS: Abusive head trauma as a mechanism was associated with MODS following TBI. Both AHT mechanism and MODS were associated with new impairment at all time points.

Use of Antifibrinolytics in Pediatric Life-Threatening Hemorrhage: A Prospective Observational Multicenter Study.

OBJECTIVES: To assess the impact of antifibrinolytics in children with life-threatening hemorrhage. DESIGN: Secondary analysis of the MAssive Transfusion epidemiology and outcomes In Children study dataset, a prospective observational study of children with life-threatening bleeding events. SETTING: Twenty-four children's hospitals in the United States, Canada, and Italy. PATIENTS: Children 0-17 years old who received greater than 40 mL/kg of total blood products over 6 hours or were transfused under activation of massive transfusion protocol. INTERVENTION/EXPOSURE: Children were compared according to receipt of antifibrinolytic medication (tranexamic acid or aminocaproic acid) during the bleeding event. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, medications administered, and clinical outcomes were analyzed using Cox proportional hazard and Kaplan-Meier survival analysis. The primary outcome was 24-hour mortality. Of 449 patients analyzed, median age was 7 years (2-15 yr), and 55% were male. The etiology of bleeding was 46% traumatic, 34% operative, and 20% medical. Twelve percent received antifibrinolytic medication during the bleeding event (n = 54 unique subjects; n = 18 epsilon aminocaproic acid, n = 35 tranexamic acid, and n = 1 both). The antifibrinolytic group was comparable with the nonantifibrinolytic group on baseline demographic and physiologic parameters; the antifibrinolytic group had longer massive transfusion protocol duration, received greater volume blood products, and received factor VII more frequently. In the antifibrinolytic group, there was significantly less 6-hour mortality overall (6% vs 17%; p = 0.04) and less 6-hour mortality due to hemorrhage (4% vs 14%; p = 0.04). After adjusting for age, bleeding etiology, Pediatric Risk of Mortality score, and plasma deficit, the antifibrinolytic group had decreased mortality at 6- and 24-hour postbleed (adjusted odds ratio, 0.29 [95% CI, 0.09-0.93]; p = 0.04 and adjusted odds ratio, 0.45 [95% CI, 0.21-0.98]; p = 0.04, respectively). CONCLUSIONS: Administration of antifibrinolytic medications during the life-threatening event was independently associated with improved 6- and 24-hour survivals in bleeding children. Consideration should be given to use of antifibrinolytics in pediatric patients with life-threatening hemorrhage.

Life-Threatening Bleeding in Children: A Prospective Observational Study.

OBJECTIVES: The purpose of our study was to describe children with life-threatening bleeding. DESIGN: We conducted a prospective observational study of children with life-threatening bleeding events. SETTING: Twenty-four childrens hospitals in the United States, Canada, and Italy participated. SUBJECTS: Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. INTERVENTIONS: Children were compared according bleeding etiology: trauma, operative, or medical. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. CONCLUSIONS: Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.

Adverse events after low titer group O whole blood versus component product transfusion in pediatric trauma patients: A propensity-matched cohort study.

BACKGROUND: Low titer group O whole blood (LTOWB) is used as the initial resuscitative fluid in an increasing number of pediatric trauma and massive bleeding transfusion protocols. There is little data on adverse events following its transfusion in pediatric trauma patients. STUDY DESIGN AND METHODS: Blood bank records were queried for pediatric recipients of at least one unit of red blood cells (RBCs) (component group) or LTOWB (LTOWB group) within 24 h of admission between May 2013 and August 2020. Subjects with early death (<72 h) were excluded. Propensity-score matching of LTOWB and component groups was performed. Adverse events were recorded, including transfusion reaction, thromboembolism, acute kidney injury, sepsis, and organ failure based on PELOD-2 score, along with hospital and ICU length of stay (LOS) and ventilator days. RESULTS: Thirty-six LTOWB recipients were matched to 36 conventional component recipients. Subjects were 52% male, with blunt injury mechanism (82%), median (IQR) injury severity score = 27 (21-35), and 26% in-hospital mortality. The groups were well matched in terms of demographics and injury characteristics. There were no clinically or statistically significant differences in adverse outcomes including reported transfusion reaction, organ failure, acute kidney injury, sepsis/bacteremia, and venous thromboembolism. Hospital LOS, ventilator days, mortality, and functional disability at discharge were also not significantly different. The LTOWB group had significantly shorter ICU LOS compared to the component group. CONCLUSION: LTOWB transfusion did not increase the risk of adverse events in children. However, larger studies are required to confirm these results.

Safety profile of low-titer group O whole blood in pediatric patients with massive hemorrhage.

BACKGROUND: Low-titer Group O Whole Blood (LTOWB) is used with increasing frequency in adult and pediatric trauma and massive bleeding transfusion protocols. There is a risk of acute hemolytic reactions in non-group O recipients due to the passive transfusion of anti-A and anti-B in the LTOWB. This study investigated the hemolysis risk among pediatric recipients of LTOWB. STUDY DESIGN AND METHODS: Blood bank records were queried for pediatric recipients of LTOWB between June 2016 and August 2020 and merged with clinical data. The primary outcome was laboratory evidence of hemolysis as manifested by changes in lactate dehydrogenase (LDH), haptoglobin, total bilirubin, reticulocyte count, potassium, and creatinine. Per protocol, these values were collected on hospital days 0-2 for recipients of LTOWB. Transfusion reactions were reported to the hospital's blood bank. RESULTS: Forty-seven children received LTOWB transfusion between 2016 and 2020; 21 were group O and 26 were non-group O. The groups were comparable in terms of the total volume of transfused blood products, demographics, and clinical outcomes. The most common indication for LTOWB transfusion was hemorrhagic shock due to trauma. There were no clinically or statistically significant differences in baseline, post-transfusion day 1, or post-transfusion day 2 hemolysis markers between the group O and non-group O LTOWB recipients. There were no adverse events or transfusion reactions reported. DISCUSSION: Use of up to 40 ml/kg of LTOWB appears to be serologically safe for children in hemorrhagic shock.

Survey to inform trial of low-titer group O whole-blood compared to conventional blood components for children with severe traumatic bleeding.

BACKGROUND: Low-titer group O whole-blood (LTOWB) is being used for children with life-threatening traumatic bleeding. A survey was conducted to determine current LTOWB utilization and interest in participation in a randomized control trial (RCT) of LTOWB versus standard blood component transfusion in this population. STUDY DESIGN AND METHODS: Transfusion medicine (TM) directors and pediatric trauma directors at 36 US children's hospitals were surveyed by e-mail in June 2020. Hospitals were selected by participation in the Massive Transfusion Epidemiology and Outcomes in Children Study or being among the largest 30 children's hospitals by bed capacity per the Becker Hospital Review. RESULTS: The response rate was 83.3% (30/36) from TM directors and 88.9% (32/36) from trauma directors. The median of massive transfusion protocol activations for traumatic bleeding was reported as 12 (IQR 5.8-20) per year by TM directors. LTOWB was used by 18.8% (6/32) of trauma directors. Survey responses indicate that 86.7% (26/30) of TM directors and 90.6% (29/32) of trauma directors either moderately or strongly agree that a LTOWB RCT is important to perform. About 83.3% (25/30) of TM directors and 93.8% (30/32) of trauma directors were willing to participate in the proposed trial. About 80% (24/30) of TM directors and 71.9% (23/32) of trauma directors would transfuse RhD+ LTOWB to male children, but fewer would transfuse Rh + LTOWB to females [20% (6/30) TM directors and 37.5% (12/32) of trauma directors]. CONCLUSIONS: A majority of respondents supported an RCT comparing LTOWB to component therapy in children with severe traumatic bleeding.

An Evaluation of Pediatric Secondary Overtriage in the Pennsylvania Trauma System.

BACKGROUND: We sought to determine the secondary overtriage rate of pediatric trauma patients admitted to pediatric trauma centers. We hypothesized that pediatric secondary overtriage (POT) would constitute a large percentage of admissions to PTC. MATERIALS AND METHODS: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2003 to 2017 for pediatric (age ≤ 18 y) trauma patients transferred to accredited pediatric trauma centers in Pennsylvania (n = 6). Patients were stratified based on discharge within (early) and beyond (late) 24 h following admission. POT was defined as patients transferred to a PTC with an early discharge. Multilevel mixed-effects logistic regression model controlling for demographic and injury severity covariates were utilized to determine the adjusted impact of injury patterns on early discharge. RESULTS: A total of 37,653 patients met inclusion criteria. For transfers, POT compromised 18,752 (49.8%) patients. Compared to POT, non-POT were more severely injured (ISS: 10 versus 6;P < 0.001) and spent less time in the ED (Min: 181 versus 207;P < 0.001). In adjusted analysis, concussion, closed skull vault fractures, supracondylar humerus fractures, and consults to neurosurgery were associated with increased odds of POT. Overall, femur fracture, child abuse evaluation, and consults to plastic surgery, orthopedics, and ophthalmology were all associated with a decreased risk of being POT. CONCLUSIONS: POT comprises 49.8% of PTC transfer admissions in Pennsylvania's trauma system. Improving community resources for management of pediatric concussion and mild TBI could result in decreased rates of POT to PTCs. Developing better inter-facility transfer guidelines and increased education of adult TC and nontrauma center hospitals is needed to decrease POT. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Clinical Deterioration and Neurocritical Care Utilization in Pediatric Patients With Glasgow Coma Scale Score of 9-13 After Traumatic Brain Injury: Associations With Patient and Injury Characteristics.

OBJECTIVES: To define the clinical characteristics of hospitalized children with moderate traumatic brain injury and identify factors associated with deterioration to severe traumatic brain injury. DESIGN: Retrospective cohort study. SETTING: Tertiary Children's Hospital with Level 1 Trauma Center designation. PATIENTS: Inpatient children less than 18 years old with an International Classification of Diseases code for traumatic brain injury and an admission Glasgow Coma Scale score of 9-13. MEASUREMENTS AND RESULTS: We queried the National Trauma Data Bank for our institutional data and identified 177 patients with moderate traumatic brain injury from 2010 to 2017. These patients were then linked to the electronic health record to obtain baseline and injury characteristics, laboratory data, serial Glasgow Coma Scale scores, CT findings, and neurocritical care interventions. Clinical deterioration was defined as greater than or equal to 2 recorded values of Glasgow Coma Scale scores less than or equal to 8 during the first 48 hours of hospitalization. Thirty-seven patients experienced deterioration. Children who deteriorated were more likely to require intubation (73% vs 26%), have generalized edema, subdural hematoma, or contusion on CT scan (30% vs 8%, 57% vs 37%, 35% vs 16%, respectively), receive hypertonic saline (38% vs 7%), undergo intracranial pressure monitoring (24% vs 0%), were more likely to be transferred to inpatient rehabilitation following hospital discharge (32% vs 5%), and incur greater costs of care ($25,568 vs $10,724) (all p < 0.01). There was no mortality in this cohort. Multivariable regression demonstrated that a higher Injury Severity Score, a higher initial international normalized ratio, and a lower admission Glasgow Coma Scale score were associated with deterioration to severe traumatic brain injury in the first 48 hours (p < 0.05 for all). CONCLUSIONS: A substantial subset of children (21%) presenting with moderate traumatic brain injury at a Level 1 pediatric trauma center experienced deterioration in the first 48 hours, requiring additional resource utilization associated with increased cost of care. Deterioration was independently associated with an increased international normalized ratio higher Injury Severity Score, and a lower admission Glasgow Coma Scale score.

Evaluation of a mobile safety center's impact on pediatric home safety behaviors.

BACKGROUND: A Mobile Safety Center (MSC) provides safety resources to families to prevent pediatric injury. The primary objective of this study was to assess the impact of an MSC on home safety behaviors. METHODS: We conducted a prospective observational study with 50 parents and guardians recruited at community events attended by an MSC. Participants completed a pre-test assessing demographics and home safety behaviors prior to participating in the MSC's home safety educational program. We conducted follow-up with participants 4 weeks (follow-up 1) and 6 months (follow-up 2) after their visit to the MSC to reassess home safety behaviors. We used descriptive statistics in addition to Friedman, Wilcoxon sum-rank, and Fisher's exact testing to analyze respondent demographics and changes in home safety practices. Friedman and Wilcoxon sum-rank testing was performed only for participants who completed all surveys. RESULTS: Of our 50 participants, 29 (58%) completed follow-up 1, 30 (60%) completed follow-up 2, and 26 (52%) completed both. Participants were more likely to have a fire-escape plan at follow-up 1 than on the pre-test (p = 0.014). They were also more likely to have the Poison Control Hotline number accessible in their cellphone or near a home phone at follow-up 1 compared to the pre-test (p = 0.002) and follow-up 2 compared to the pre-test (p < 0.001). Families with at least one household member who smoked or used e-cigarettes at any point during the study (n = 16 for the total population, n = 9 for those who completed both surveys) were less likely to have more than two smoke detectors installed at home during the pre-test (p = 0.049). However, this significantly changed across timepoints (p = 0.018), and while 44.4% reported more than two detectors during the pre-test, 88.9% reported this at both follow-ups. CONCLUSIONS: Home safety education through an MSC positively changed some reported safety behaviors and maintained these changes at long-term follow-up. By encouraging the adoption of better home safety practices, education at an MSC may decrease pediatric injury rates.

Whole Blood is Superior to Component Transfusion for Injured Children: A Propensity Matched Analysis.

OBJECTIVE: To compare a propensity-matched cohort of injured children receiving conventional blood component transfusion to injured children receiving low-titer group O negative whole blood. SUMMARY OF BACKGROUND DATA: Transfusion of whole blood in pediatric trauma patients is feasible and safe. Effectiveness has not been evaluated. METHODS: Injured children ≥1 years old can receive up to 40 mL/kg of cold-stored, uncrossmatched whole blood during initial hemostatic resuscitation. Whole blood recipients (2016-2019) were compared to a propensity-matched cohort who received at least 1 uncrossmatched red blood cell unit in the trauma bay (2013-2016). Cohorts were matched for age, hypotension, traumatic brain injury, injury mechanism, and need for emergent surgery. Outcomes included time to resolution of base deficit, product volumes transfused, and INR after resuscitation. RESULTS: Twenty-eight children who received whole blood were matched to 28 children who received components. The whole blood group had faster time to resolution of base deficit [median (IQR) 2 (1-2.5) hours vs 6 (2-24) hours, respectively; P < 0.001]. The post-transfusion INR was decreased in whole blood vs component cohort [median (IQR) 1.4 (1.3-1.5) vs 1.6 (1.4-2.2); P = 0.01]. Lower plasma volumes [median (IQR) = 5 (0-15) mL/kg vs 11 (5-35) mL/kg; P = 0.04] and lower platelet volumes [median (IQR) = 0 (0-2) vs 3 (0-8); P = 0.03] were administered to the whole blood group versus component group. Other clinical variables (in-hospital death, hospital length of stay, intensive care unit length of stay, and ventilator days) did not differ between groups. CONCLUSIONS: Compared to component transfusion, whole blood transfusion results in faster resolution of shock, lower post-transfusion INR, and decreased component product transfusion. Larger cohorts are required to support these findings.

Trauma-Induced Coagulopathy in Children.

Trauma-induced coagulopathy (TIC) is well documented in injured children. However, many important features of pediatric hemostasis are still in development in early childhood and may impact TIC. Certain pediatric subgroups are at a higher risk. Traumatic brain injury, which occurs with a higher rate in children, and physical child abuse are known risk factors for TIC that deserve special consideration. Resuscitation of a pediatric trauma patient follows many of the same goals as in the injured adult trauma, although some key aspects of pediatric resuscitation require ongoing investigation. Venous thromboembolism occurs with higher rates in certain high-risk groups of pediatric trauma patients, although overall it is considerably less frequent in children as compared with adults.

The Presence of Anemia in Children with Abusive Head Trauma.

OBJECTIVES: To evaluate the incidence of anemia in patients with abusive head trauma (AHT), noninflicted traumatic brain injury (TBI), and physical abuse without AHT and the effect of anemia on outcome. STUDY DESIGN: In a retrospective, single-center cohort study, we included children under the age of 3 years diagnosed with either AHT (n = 75), noninflicted TBI (n = 77), or physical abuse without AHT (n = 60) between January 1, 2014, and December 31, 2016. Neuroimaging was prospectively analyzed by pediatric neuroradiologists. Primary outcome was anemia at hospital presentation. Secondary outcomes included unfavorable outcome at hospital discharge, defined as a Glasgow Outcome Scale between 1 and 3, and intracranial hemorrhage (ICH) volume. RESULTS: Patients with AHT had a higher rate of anemia on presentation (47.3%) vs noninflicted TBI (15.6%) and physical abuse without AHT (10%) (P < .001). Patients with AHT had larger ICH volumes (33.3 mL [10.1-76.4 mL] vs 1.5 mL [0.6-5.2 mL] ; P < .001) and greater ICH/total brain volume percentages than patients with noninflicted TBI (4.6% [1.4-8.2 %] vs 0.2% [0.1-0.7%]; P < .001). Anemia was associated with AHT (OR, 4.7; 95% CI, 2.2-10.2) and larger ICH/total brain volume percentage (OR, 1.1; 95% CI, 1.1-1.2) in univariate analysis. Unfavorable outcome at hospital discharge was associated with anemia (OR, 4.4; 95% CI, 1.6-12.6) in univariate analysis, but not after controlling for covariates. CONCLUSIONS: Patients with AHT were more likely to present to the hospital with anemia and increased traumatic ICH volume than patients with noninflicted TBI or physical abuse without AHT. Children with anemia and AHT may be at increased risk for an unfavorable outcome.

Window of Opportunity to Mitigate Trauma-induced Coagulopathy: Fibrinolysis Shutdown not Prevalent Until 1 Hour Post-injury.

OBJECTIVE: The aim of this study was to delineate the kinetics of coagulation dysregulation after injury in children. SUMMARY BACKGROUND DATA: Trauma-induced coagulopathy is common and portends poor outcomes in severely-injured children. Transfer to pediatric trauma centers is common; time from injury to laboratory testing is therefore highly variable. METHODS: Records of severely injured children age <18 years with rapid thromboelastography (TEG) on arrival and documented time of injury were queried. Standard definitions of hyperfibrinolysis (LY30 ≥3), fibrinolysis shutdown (SD; LY30 ≤0.8), and physiologic (LY30 = 0.9-2.9) were applied. Abbreviated Injury Scale score ≥3 defined severe traumatic brain injury (TBI). Variables of interest included demographics, injury mechanism, medications, mortality, and functional disability. Wilcoxon rank-sum and Kruskal-Wallis testing were utilized for skewed continuous data, and Chi-square or Fisher exact test was used for categorical data. To determine independent predictors of SD, multivariable logistic regression modeling was performed using the time from injury variable as well as variables determined a priori to be clinically relevant contributors to the development of SD (TBI, injury mechanism, and age). RESULTS: A total of 285 patients were included: median (interquartile range) age = 11 (6-15), injury severity score = 17 (10-25), 75% blunt mechanism, 32% severe TBI, 11% mortality, 28% functional disability. None received antifibrinolytics or blood products before TEG testing. Physiologic phenotype was predominant within 1 hour of injury (51%); beyond 1 hour, fibrinolysis SD was the predominant phenotype (1-3 hours = 46%, >3 hours = 59%). Patients with TBI had significant increase in incidence of fibrinolysis SD beyond 1 hour after injury as compared to non-TBI patients. Physiologic fibrinolysis was associated with survival at all timepoints (P = 0.005). CONCLUSIONS: Fibrinolysis SD is a reactive, compensatory mechanism that is evident soon after injury. There appears to be an early and brief window of opportunity for intervention to mitigate the progression to TIC. Further studies should focus on understanding the dynamic events occurring immediately after injury to identify specific targets for intervention.

Seasonal, Weather, and Temporal Factors in the Prediction of Admission to a Pediatric Trauma Center.

BACKGROUND: Our objective is to identify seasonal and weather trends associated with pediatric trauma admissions. METHODS: We reviewed all trauma activations leading to admission in patients ≤18 years admitted to a regional pediatric trauma center from January 1, 2000, to December 31, 2015. We reviewed climatologic measures of the mean temperature, mean visibility, and precipitation for each admission in the 6 h prior to each presentation in addition to time of arrival, weekday/weekend presentation, and season. We used a negative binomial regression model with multivariable analysis to estimate associations between weather and rate of trauma admissions. Results were presented as incidence rate ratios (IRR) with 95% confidence intervals (CI). RESULTS: In total, 3856 encounters [2539 males (65.8%), mean age 10.2 years ± SD 5.1 years] were included. Results from multivariable analysis (IRR, 95% CI) suggested an association of admissions with rain (0.82, 0.75-0.90) and overnight hours (23:51-05:50; 0.69, 0.58-0.82) as compared to morning (05:51-11:50). The IRR of trauma increased during the afternoon (11:51-17:50; 4.05, 3.57-4.61), night periods (17:51-23:50; 5.59, 4.94-6.33), and weekends (1.24, 1.15-1.32), and with every 1 °C increase in temperature (1.04, 1.03-1.04). After accounting for other variables, season was not found to be independently predictive of trauma admission. CONCLUSION: Trauma admissions had a higher rate during afternoon, evening hours, and weekends. The presence of rain lowered the rate of pediatric trauma admission. Each degree increase in temperature increased the rate of trauma admissions by 4%. The findings provide information from the perspective of emergency preparedness, resource utilization, and staffing to pediatric trauma centers.

Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications.

Despite over a half-century of recognizing fibrinolytic abnormalities after trauma, we remain in our infancy in understanding the underlying mechanisms causing these changes, resulting in ineffective treatment strategies. With the increased utilization of viscoelastic hemostatic assays (VHAs) to measure fibrinolysis in trauma, more questions than answers are emerging. Although it seems certain that low fibrinolytic activity measured by VHA is common after injury and associated with increased mortality, we now recognize subphenotypes within this population and that specific cohorts arise depending on the specific time from injury when samples are collected. Future studies should focus on these subtleties and distinctions, as hypofibrinolysis, acute shutdown, and persistent shutdown appear to represent distinct, unique clinical phenotypes, with different pathophysiology, and warranting different treatment strategies.