Prehospital transfusion in kids may lower rates of mortality compared with transfusion on arrival: JAMA

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. Clinicians must be vigilant for signs of shock (altered mentation, tachycardia, and hypotension) in injured children and implement early hemostatic resuscitation as needed.

In a recent cohort study of a statewide trauma database, published in JAMA Pediatrics found the association of prehospital blood transfusion (PHT) in injured children who received PHT had significantly lower odds of 24-hour and in-hospital mortality compared with injured children who received a transfusion in the emergency department. For every unit of red blood cells transfused in the prehospital setting, children had 2 times increased odds of survival.

The retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT). Interfacility transfers and isolated burn mechanism were excluded. The study looked into primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications.

The key findings of the study are

• Total of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age, sex (46 [66%] vs 337 [69%] were male), and insurance status.

• The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]).

• Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups.

• Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications.

• Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour and in-hospital mortality compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child’s life was 5.

In conclusion, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation.

Reference: Morgan KM, Abou-Khalil E, Strotmeyer S, Richardson WM, Gaines BA, Leeper CM. Association of Prehospital Transfusion With Mortality in Pediatric Trauma. JAMA Pediatr. 2023;177(7):693–699. doi:10.1001/jamapediatrics.2023.1291.