Prehospital and Resuscitation - The Eastern Association for the Surgery of Trauma

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Eastern Association for the Surgery of Trauma

Prehospital and Resuscitation

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study

Polites SF, Moody S, Williams RF, Kayton ML, Alberto EC, Burd RS, Schroeppel TJ, Baerg JE, Munoz A, Rothstein WB, Boomer LA, Campion EM, Robinson C, Nygaard RM, Richardson CJ, Garcia DI, Streck CJ, Gaffley M, Petty JK, Greenwell C, Pandya S, Waters AM, Russell RT, Yorkgitis BK, Mull J, Pence J, Santore MT, MacArthur T, Klinkner DB, Safford SD, Trevilian T, Vogel AM, Cunningham M, Black C, Rea J, Spurrier RG, Jensen AR, Farr BJ, Mooney DP, Ketha B, Dassinger III MS, Goldenberg-Sandau A, Roman JS, Jenkins TM, Falcone, Jr RA.

J Trauma Acute Care Surg. 2020 Jul;89(1):36-42.

Rationale for inclusion: Large, prospective multicenter study examining the use of crystalloid and transfusion practices in the resuscitation of hemorrhagic shock. The association between increased crystalloid use and prolonged mechanical ventilation and length of ICU and hospital stay reinforces the increasingly accepted practice in adult trauma of avoiding crystalloids for trauma resuscitation.

CAVEAT: Observational study, can only demonstrate association.

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The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients.

Phillips R, Acker SN, Shahi N, Meier M, Leopold D, Recicar J, Kulungowski A, Patrick D, Moulton S, Bensard D.

J Pediatr Surg. 2020 Feb;55(2):331-334.

Rationale for inclusion: Based on 66 of 211 pediatric trauma patients who required massive transfusion, this single-center study establishes the "ABCD" score as highly sensitive and accurate tool to predict the need for massive transfusion in pediatric trauma patients. The ABCD score adds shock index, base deficit, and lactate levels to the well-established ABC score.

CAVEAT: Retrospective, registry-based study; small study population; all requirements to calculate ABCD score may not be available at time for MTP decision

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Effect of Fresh vs Standard-issue Red Blood Cell Transfusions on Multiple Organ Dysfunction Syndrome in Critically Ill Pediatric Patients: A Randomized Clinical Trial

Spinella PC, Tucci M, Fergusson DA, Lacroix J, Hébert PC, Leteurtre S, Schechtman KB, Doctor A, Berg RA, Bockelmann T, Caro TJ, Chiusolo F, Clayton L, Cholette JM, Guerra GG, Josephson CD, Menon K, Muszynski JA, Nellis ME, Sarpal A, Schafer S, Steiner ME, Turgeon AF, ABC-PICU Investigators, the Canadian Critical Care Trials Group, the Pediatric Acute Lung Injury and Sepsis Investigators Network, the BloodNet Pediatric Critical Care Blood Research Network, and the Groupe Francophone de Réanimation et Urgences P.

JAMA. 2019 Dec 10;322(22):2179-2190.

Rationale for inclusion: Large, international, multicenter RCT that did not detect a significant difference in the incidence of new/progressive organ dysfunction after transfusing "fresh" (median 5 days) vs. "old" (median 18 days) red blood cells in critically ill children up to age 16 years. Similar to the adult literature, this RCT contradicts the findings of observational and retrospective studies that raised concern about the negative effects of "old" blood transfusions due to storage lesion and other concerns.

CAVEAT: Despite a large number of participants, may have been underpowered in certain subgroups; heterogeneity expected with an international multi-center trial.

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Prevalence and Impact of Admission Acute Traumatic Coagulopathy on Treatment Intensity, Resource Use, and Mortality: An Evaluation of 956 Severely Injured Children and Adolescents.

Liras IN, Caplan HW, Stensballe J, Wade CE, Cox CS, Cotton BA.

J Am Coll Surg. 2017 Apr;224(4):625-632.

Rationale for inclusion: This retrospective review of 956 highest-level activation pediatric trauma patient evaluated used deranged r-TEG parameters to define acute traumatic coagulopathy. Children with coagulopathy had higher mortality, ICU days and ventilator days. This was especially true in children with head injuries. This study introduces r-TEG as a useful tool to assess coagulopathy in injured chidren.

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Acute traumatic coagulopathy in a critically injured pediatric population: Definition, trend over time, and outcomes.

Leeper CM, Kutcher M, Nasr I, McKenna C, Billiar T, Neal M, Sperry J, Gaines BA.

J Trauma Acute Care Surg. 2016 Jul;81(1):34-41.

Rationale for inclusion: This ten year retrospective review of 776 children revealed that even a mild elevation of INR, 1.3 or greater, at admission and at 24h is associated with significantly increased mortality. This association was independent of transfusion, suggesting that the INR is a marker of coagulopathy rather than a target for correction. This is an important paper to describe the phenomenon of acute traumatic coagulopathy in children.

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Pediatric specific shock index accurately identifies severely injured children.

Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD.

J Pediatr Surg. 2015 Feb;50(2):331-4.

Rationale for inclusion: This retrospective review of 543 injured children age 4-16 years evaluated the ability of a pediatric adjusted shock index to identify the most severely injured patients. The shock index-pediatric adjusted (SIPA) is calculated by the heart rate divided by the systolic blood pressure compared to age-specific normal limits. SIPA showed superior ability to discriminate sevely injured children compared to the standard shock index, though many severely injured children did not have an elevated SIPA.

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Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data.

Neff LP, Cannon JW, Morrison JJ, Edwards MJ, Spinella PC, Borgman MA.

J Trauma Acute Care Surg. 2015 Jan;78(1):22-8; discussion 28-9.

Rationale for inclusion: The Department of Defense Trauma Registry was used to identify 1,113 combat-injured pediatric trauma patients who received blood product transfusion. Sensitivity and specificity curves for early and in-hospital mortality identified a transfusion threshold of 40 mL/kg of all blood products in the first 24h as the optimal definition for massive transfusion in children. This paper provides the most evidence based threshold for pediatric massive transfusion to date.

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Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX).

Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S, Martin MJ.

J Trauma Acute Care Surg. 2014 Dec;77(6):852-8; discussion 858.

Rationale for inclusion: This retrospective review evaluated 766 children who were treated in the recent conflict in Afghanistan. Severely injured children were matched on demographics, vital signs, injuries, and labs. In this severely injured, penetrating mechanism-heavy group, children who received TXA experienced decreased mortality and improved neurologic outcome.

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Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial.

Adelson PD, Wisniewski SR, Beca J, Brown SD, Bell M, Muizelaar JP, Okada P, Beers SR, Balasubramani GK, Hirtz D; Paediatric Traumatic Brain Injury Consortium.

Lancet Neurol. 2013 Jun;12(6):546-53.

Rationale for inclusion: This phase 3, multicenter, multinational, randomized controlled trial compared hypothermia to normothermia for children with severe traumatic brain injury. The study was terminated early for futility following an interim data analysis on data for that showed no between-group difference in mortality, poor outcomes, or adverse/serious events 3 months after injury. They authors concluded that hypothermia for 48 h with slow rewarming does not reduce mortality of improve global functional outcome after pediatric severe traumatic brain injury.

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A comparison of high-dose and standard-dose epinephrine in children with cardiac arrest.

Perondi MB, Reis AG, Paiva EF, Nadkarni VM, Berg RA.

N Engl J Med. 2004 Apr 22;350(17):1722-30.

Rationale for inclusion: This prospective, randomized, double-blind study of 68 children showed that patients in the high-dose group (0.1 mg/kg) had no difference in return of spontaneous circulation and worse 24-hour mortality and survival to discharge compared to standard dose (0.01 mg/kg) epinephrine.

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Predicting survival in pediatric trauma patients receiving cardiopulmonary resuscitation in the prehospital setting.

Perron AD, Sing RF, Branas CC, Huynh T.

Prehosp Emerg Care. 2001 Jan-Mar;5(1):6-9.

Rationale for inclusion: This study was a large, retrospective registry review of 729 pediatric trauma patients receiving CPR in the field from 1998-2005. The authors found that prehospital intubation, penetrating mechanism, and receiving additional CPR at the trauma center were predictors of mortality. Overall mortality was 29%.

CAVEAT: Retrospective, trauma registry.

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Predicting survival in pediatric trauma patients receiving cardiopulmonary resuscitation in the prehospital setting.

Perron AD, Sing RF, Branas CC, Huynh T.

Prehosp Emerg Care. 2001 Jan-Mar;5(1):6-9.

Rationale for inclusion: This study was a large, retrospective registry review of 729 pediatric trauma patients receiving CPR in the field from 1998-2005. The authors found that prehospital intubation, penetrating mechanism, and receiving additional CPR at the trauma center were predictors of mortality. Overall mortality was 29%.

CAVEAT: Retrospective, trauma registry

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Early fluid resuscitation improves outcomes in severely burned children.

Barrow RE, Jeschke MG, Herndon DN.

Resuscitation. 2000 Jul;45(2):91-6.

Rationale for inclusion: This single institution, retrospective review of 133 children with greater than 50% TBSA burns showed that sepsis, acute kidney injury, and overall mortality was significantly increased when initiation of fluid resuscitation was delayed by two hours or more.

CAVEAT: Single institution, retrospective

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Early fluid resuscitation improves outcomes in severely burned children.

Barrow RE, Jeschke MG, Herndon DN.

Resuscitation. 2000 Jul;45(2):91-6.

Rationale for inclusion: This single institution, retrospective review of 133 children with greater than 50% TBSA burns showed that sepsis, acute kidney injury, amd overall mortality was significantly increased when initiation of fluid resuscitation was delayed by two hours or more.

CAVEAT: Single institution, retrospective.

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Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.

Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS.

JAMA. 2000 Feb 9;283(6):783-90.

Rationale for inclusion: This prospective, randomized (by odd/even date of arrest), observational, multi-center evaluation of 830 pediatric patients requiring advanced airway management from 1994-1997 compared prehospital endotracheal intubation (N=420) to bag mask ventilation (BVM) (N=410) and found no difference in survival or neurologic outcome. This suggests that BVM is sufficient for prehospital management of the pediatric airway.

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Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial.

Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS.

JAMA. 2000 Feb 9;283(6):783-90.

Rationale for inclusion: This prospective, randomized (by odd/even date of arrest), observational, multicenter evaluation of 830 pediatric patients requiring advanced airway management from 1994-1997 compared prehospital endotracheal intubation (N=420) to bag mask ventilation (BVM) (N=410) and found no difference in survival or neurologic outcome. This suggests that BVM is sufficient for prehospital management of the pediatric airway.

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Rib fractures in children--resuscitation or child abuse?

Betz P, Liebhardt E.

Int J Legal Med. 1994;106(4):215-8.

Rationale for inclusion: This autopsy study of 233 infants and children helped define the rib fracture pattern (anterior) that is rarely seen with resuscitaion and closed-chest massage. This study refutes the hypothesis that rib fractures in children are caused by "inexperienced resuscitation in a panic-like reaction".

CAVEAT: Retrospective.

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A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group.

Lubitz DS, Seidel JS, Chameides L, Luten RC, Zaritsky AL, Campbell FW.

Ann Emerg Med. 1988 Jun;17(6):576-81.

Rationale for inclusion: This first published use of the Broselow tape was a prospective, blinded, observational study of 937 children that compared the weight derived from the Broselow tape to patient's actual weight. Broeslow tape performace was best in the 2.5 kg-10 kg and 10 kg-25 kg weigh ranges. These results enabled further development of the Broselow tape and led to its widespread use in pediatric trauma to assess weight and weight-based drug dosage.

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Intraosseous fluid administration: a parenteral alternative in pediatric resuscitation.

Harte FA, Chalmers PC, Walsh RF, Danker PR, Sheikh FM.

Anesth Analg. 1987 Jul;66(7):687-9.

Rationale for inclusion: This early case report describes the use of the intraosseous vascular access for resuscitation in critically ill children.

CAVEAT: Case report.

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