Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion

Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study

OBJECTIVE

The number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival.

METHODS

A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0-14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule.

RESULTS

During the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2-10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75-91), a specificity of 82 % (95 % CI 81-82), and a negative predictive value of 99.96 % (95 % CI 99.94-99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77-94), the specificity of 57 % (95 % CI 54-59), and the negative predictive value was 98.97 % (95 % CI 98.13-99.44).

CONCLUSIONS

A limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

The Shock Index among Children Presenting to the Emergency Department: Analysis of Nationally Representative Sample

BACKGROUND

The Shock Index (SI) is emerging as a potentially useful measure among children with injury or suspected sepsis.

OBJECTIVE

The aim of this study was to evaluate the distribution of the SI and evaluate its association with clinical outcomes among all children presenting to the emergency department (ED).

METHODS

A complex survey of nonfederal U.S. ED encounters from 2016 through 2021 was analyzed. Among children, the Pediatric Age-Adjusted Shock Index (SIPA), Pediatric Shock Index (PSI), and the Temperature- and Age-Adjusted Shock Index (TAMSI) were analyzed. The association of these criteria with disposition, acuity, medication administration, diagnoses and procedures was analyzed.

RESULTS

A survey-weighted 81.5 million ED visits were included for children aged 4-16 years and 117.2 million visits were included for children aged 1-12 years. SI could be calculated for 78.6% of patients aged 4-16 years and 57.9% of patients aged 1-12 years. An abnormal SI was present in 15.9%, 11.1%, and 31.7% when using the SIPA, PSI, and TAMSI, respectively. With all criteria, an elevated SI was associated with greater hospitalization. The SIPA and PSI were associated with triage acuity. All criteria were associated with medical interventions, including provision of IV fluids and acquisition of blood cultures.

CONCLUSIONS

An elevated SI is indicative of greater resource utilization needs among children in the ED. When using any criteria, an elevated SI was associated with clinically important outcomes. Further research is required to evaluate the distribution of the SI in children and to investigate its potential role within existing triage algorithms for children in the ED.

HEMORRHAGIC SHOCK ASSESSED BY TISSUE MICROCIRCULATORY MONITORING: A NARRATIVE REVIEW

ABSTRACT

Hemorrhagic shock (HS) is a common complication after traumatic injury. Early identification of HS can reduce patients' risk of death. Currently, the identification of HS relies on macrocirculation indicators such as systolic blood pressure and heart rate, which are easily affected by the body's compensatory functions. Recently, the independence of the body's overall macrocirculation from microcirculation has been demonstrated, and microcirculation indicators have been widely used in the evaluation of HS. In this study, we reviewed the progress of research in the literature on the use of microcirculation metrics to monitor shock. We analyzed the strengths and weaknesses of each metric and found that microcirculation monitoring could not only indicate changes in tissue perfusion before changes in macrocirculation occurred but also correct tissue perfusion and cell oxygenation after the macrocirculation index returned to normal following fluid resuscitation, which is conducive to the early prediction and prognosis of HS. However, microcirculation monitoring is greatly affected by individual differences and environmental factors. Therefore, the current limitations of microcirculation assessments mean that they should be incorporated as part of an overall assessment of HS patients. Future research should explore how to better combine microcirculation and macrocirculation monitoring for the early identification and prognosis of HS patients.

Association of Contrast Extravasation Grade With Massive Transfusion in Pediatric Blunt Liver and Spleen Injuries: A Multicenter Retrospective Cohort Study

BACKGROUND

This study aimed to assess whether the grade of contrast extravasation (CE) on CT scans was associated with massive transfusion (MT) requirements in pediatric blunt liver and/or spleen injuries (BLSI).

METHODS

This multicenter retrospective cohort study included pediatric patients (≤16 years old) who sustained BLSI between 2008 and 2019. MT was defined as transfusion of all blood products ≥40 mL/kg within the first 24 h of admission. Associations between CE and MT requirements were assessed using multivariate logistic regression analysis with cluster-adjusted robust standard errors to calculate the adjusted odds ratio (AOR).

RESULTS

A total of 1407 children (median age: 9 years) from 83 institutions were included in the analysis. Overall, 199 patients (14 %) received MT. CT on admission revealed that 54 patients (3.8 %) had CE within the subcapsular hematoma, 100 patients (7.1 %) had intraparenchymal CE, and 86 patients (6.1 %) had CE into the peritoneal cavity among the overall cohort. Multivariate analysis, adjusted for age, sex, age-adjusted shock index, injury severity, and laboratory and imaging factors, showed that intraparenchymal CE and CE into the peritoneal cavity were significantly associated with the need for MT (AOR: 2.50; 95 % CI, 1.50-4.16 and AOR: 4.98; 95 % CI, 2.75-9.02, respectively both p < 0.001). The latter significant association persisted in the subgroup of patients with spleen and liver injuries.

CONCLUSION

Active CE into the free peritoneal cavity on admission CT was independently associated with a greater probability of receiving MT in pediatric BLSI. The CE grade may help clinicians plan blood transfusion strategies.

LEVEL OF EVIDENCE

Level 4; Therapeutic/Care management.

Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care

BACKGROUND

Appropriate prehospital trauma triage ensures transport of children to facilities that provide specialized trauma care. There are currently no objective and generalizable scoring tool for emergency medical services to facilitate such decisions. An abnormal reverse shock index times Glasgow Coma Scale (rSIG), which is calculated using readily available parameters, has been shown to be associated with severely injured children. This study sought to determine if rSIG could be used in the prehospital setting to identify injured children who require the highest levels of care.

METHODS

Patients (1-18 years old) transferred from the scene to a level 1 pediatric trauma center from 2010 to 2020 with complete prehospital and emergency department vital signs, and Glasgow Coma Scale (GCS) scores were included. Reverse shock index times GCS was calculated as previously described ((systolic blood pressure/heart rate) × GCS), and the following cutoffs were used: ≤13.1, ≤16.5, and ≤20.1 for 1- to 6-, 7- to 12-, and 13- to 18-year-old patients, respectively. Trauma activation level and clinical outcomes upon arrival to the pediatric trauma center were collected.

RESULTS

There were 247 patients included in the analysis; 66.0% (163) had an abnormal prehospital rSIG. Patients with an abnormal rSIG had a higher rate of highest-level trauma activation compared with those with a normal rSIG (38.7% vs. 20.2%, p = 0.013). Patients with an abnormal prehospital rSIG also had higher rates of intubation (28.8% vs. 9.52%, p < 0.001), intracranial pressure monitor (9.20 vs. 1.19%, p = 0.032), need for blood (19.6% vs. 8.33%, p = 0.034), laparotomy (7.98% vs. 1.19%, p = 0.039), and intensive care unit admission (54.6% vs. 40.5%, p = 0.049).

CONCLUSION

Reverse shock index times GCS may assist emergency medical service providers in early identification and triage of severely injured children. An abnormal rSIG in the emergency department is associated with higher rates of intubation, need for blood transfusion, intracranial pressure monitoring, laparotomy, and intensive care unit admission. Use of this metric may help to speed the identification, care, and treatment of any injured child.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level IV.

Completeness of Pediatric Versus Adult Patient Assessment Documentation in the National Emergency Medical Services Information System

BACKGROUND

Pediatric prehospital encounters are proportionally low-frequency events. National pediatric readiness initiatives have targeted gaps in prehospital pediatric assessment and management. Regional studies suggest that pediatric vital signs are inconsistently obtained and documented. We aimed to assess national emergency medical services (EMS) data to evaluate completeness of assessment documentation for pediatric versus adult patients and to identify the documentation of condition-specific assessments.

METHODS

We performed a retrospective cross-sectional analysis of EMS encounters from the National Emergency Medical Services Information System for 2019, including all 9-1-1 encounters resulting in transport. Our primary outcome was the proportion of encounters with complete vital signs (heart rate, respiratory rate, and systolic blood pressure) documented by pediatric age category relative to adult encounters. Pediatric patients were considered as those less than 18 years old. Our secondary outcome was condition-specific assessments for encounters with respiratory emergencies, cardiac complaints, and trauma. We performed multivariable logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for vital signs documentation by age after adjusting for sex, injury status, transport type (advanced vs basic life support), census region, urbanicity, organization nonprofit status, and organization type.

RESULTS

Of 18,918,914 EMS encounters, 6.4% involved pediatric patients. Documentation of complete vital signs was lowest in those <1 month old (30.8%) and rose with increasing age (highest in adults; 91.8%). Relative to adults, the adjusted odds of documented complete vital signs in patients <1 month old was 0.03 (95% CI 0.03-0.03) and increased with age to 0.76 (95% CI 0.75-0.77) in those 12-17 years old. Among those patients with respiratory, cardiac, and traumatic complaints, children had lower proportions of documented pulse oximetry, monitor use, and pain scores, respectively, compared to adults.

CONCLUSION

Documentation of complete vital signs and condition-specific assessments occurs less frequently in children, especially in younger age groups, as compared to adults, which is a finding that exists across urbanicity, region, and level of response. These findings provide a benchmark for clinical care, quality improvement, and research in the prehospital setting.

Prehospital vital sign monitoring in paediatric patients: an interregional study of educational interventions

BACKGROUND

Prehospital vital sign documentation in paediatric patients is incomplete, especially in patients ≤ 2 years. The aim of the study was to increase vital sign registration in paediatric patients through specific educational initiatives.

METHODS

Prospective quasi-experimental study with interrupted time-series design in the North Denmark and South Denmark regions. The study consecutively included all children aged < 18 years attended by the emergency medical service (EMS) from 1 July 2019 to 31 December 2021. Specific educational initiatives were conducted only in the North Denmark EMS and included video learning and classroom training based on the European Paediatric Advanced Life Support principles. The primary outcome was the proportion of patients who had their respiratory rate, peripheral capillary oxygen saturation, heart rate and level of consciousness recorded at least twice. We used a binomial regression model stratified by age groups to compare proportions of the primary outcome in the pre- and post-intervention periods in each region.

RESULTS

In North Denmark, 7551 patients were included, while 15,585 patients from South Denmark were used as a reference. Virtually all of the North Denmark EMS providers completed the video learning (98.7%). The total study population involved patients aged ≤ 2 months (5.5%), 3-11 months (7.4%), 1-2 years (18.8%), 3-7 years (16.2%) and ≥ 8 years (52.1%). In the intervention region, the primary outcome increased from the pre- to the post-intervention period from 35.3% to 40.5% [95% CI for difference 3.0;7.4]. There were large variations in between age groups with increases from 18.8% to 27.4% [95% CI for difference 5.3;12.0] among patients aged ≤ 2 years, from 33.5% to 43.7% [95% CI for difference 4.9;15.5] among patients aged 3-7 years and an insignificant increase among patients aged ≥ 8 years (from 46.4% to 47.9% [95% CI for difference - 1.7;4.7]). In the region without the specific educational interventions, proportions were steady for all age groups throughout the entire study period.

CONCLUSIONS

Mandatory educational initiatives for EMS providers were associated with an increase in the extent of vital sign registration in paediatric patients ≤ 7 years. Incomplete vital registration was associated with, but not limited to non-urgent cases.

Nationwide estimates of the need for prehospital blood products after injury

INTRODUCTION

Prehospital blood product resuscitation after injury significantly decreases risk of mortality. However, the number of patients who may potentially benefit from this life-saving intervention is currently unknown. The primary objective of this study was to estimate the number of patients who may potentially benefit from prehospital blood product resuscitation after injury in the United States. The secondary objective was to estimate the amount of blood products needed for prehospital resuscitation of injured patients.

METHODS

Patients ≥16 years with blunt/penetrating injuries included in National Emergency Medical Services Information System 2019 were identified and classified into four separate cohorts of hemodynamic instability: Cohort 1 (systolic blood pressure [SBP] <90 mmHg), Cohort 2 (SBP <90 and/or heart rate [HR] >120), Cohort 3 (SBP <90 and HR >108 or SBP <70), and Cohort 4 (shock index ≥1). The need for prehospital blood was estimated by multiplying number of patients in each cohort with average number of blood products used for prehospital resuscitation.

RESULTS

After exclusions, 3.7 million adult trauma patients were included. The number of patients who may potentially benefit from prehospital blood products was estimated as 89,391 (Cohort 1), 901,346 (Cohort 2), 54,160 (Cohort 3), and 300,475 (Cohort 4). Assuming 1 unit of whole blood is needed per patient, a lower-bound estimate of 54,160 additional whole blood units (0.6% of current collections) will be need for prehospital resuscitation of the injured.

CONCLUSIONS

Annually, between 54,000 and 900,000 patients may potentially benefit from prehospital blood product resuscitation after injury in the United States. Prehospital blood utilization and collection of blood products will need to be increased to scale-up this life-saving intervention nationwide.

Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment

BACKGROUND

Trauma is the leading cause of pediatric mortality in the United States. Often, these patients require supermassive transfusion (SMT), which we define as receipt of >80 mL/kg blood products, double the proposed volume for standard pediatric massive transfusion (MT). Evaluating the blood volumes, injury patterns, clinical findings, and prehospital interventions predictive for SMT are critical to reducing pediatric mortality. We describe the pediatric casualties, injury patterns, and clinical findings that comprise SMT.

METHODS

We retrospectively analyzed pediatric trauma data from the Department of Defense Trauma Registry from January 2007-2016. We stratified patients into two cohorts based on blood products received in the first 24 h after injury: 1) those who received 40-80 mL/kg (MT), or 2) those who received >80 mL/kg (SMT). We evaluated demographics, injury patterns, prehospital interventions, and clinical findings.

RESULTS

Our original dataset included 3439 pediatric casualties. We identified 536 patients who met inclusion parameters (receipt of ≥40 mL/kg of blood products [whole blood, packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate]). The MT cohort included 271 patients (50.6%), and the SMT cohort comprised 265 patients (49.4%). Survival to discharge was significantly lower (78% for SMT, 86% for MT; p < 0.011) in the SMT cohort. Multivariable analysis of injury patterns revealed serious injuries (Abbreviated Injury Scale 3-6) to the extremities (OR 2.13, 95% CI 1.45-3.12) and abdomen (OR 1.65, 1.08-2.53) were associated with SMT. Wound dressings (41% versus 29%; p = 0.003), tourniquets (23% vs 12%; p = 0.001), and IO access (17% vs 10%; p = 0.013) were more common in the SMT group. Age-adjusted hypotension was significantly higher in the SMT group (41%, n = 100 vs 23%, n = 59; p < 0.001) with no statistical difference detected in tachycardia (87%, n = 223 vs 87%, n = 228; p = 0.932).

CONCLUSIONS

Our research demonstrates that pediatric SMT patients are at increased risk of mortality. Our study highlights the seriousness of extremity injuries in pediatric trauma patients, identifying associations between severe injuries to the extremities and abdomen with the receipt of SMT. Prehospital interventions of wound dressing, tourniquets, and IO access were more frequent in the SMT cohort. Our research determined that hypotension was associated with SMT, but tachycardia was not a reliable predictor of SMT over MT.