Too Little Too Late: Hypotension and Blood Transfusion in the Trauma Bay Independently Increase Odds of Early, Intermediate and Late Death
Christine M Leeper, Christine McKenna, *Barbara A Gaines
Children's Hospital of Pittsburgh of UPMC, pittsburgh, PA
Background (issue): Hypotension is a late finding in pediatric shock despite significant blood loss; consequently, recognition of hemodynamic compromise can be delayed. We sought to describe the impact of late stage hemorrhagic shock in children, indicated by hypotension or trauma bay blood transfusion, and quantify the association with poor outcome.
Methods: Children age<18 from the Pennsylvania Trauma Outcome Study registry (2000-2013) were included. Primary outcome was mortality. Demographics, transfusion volume, vitals and injury severity were recorded. Multivariable logistic regression modeling was performed, with multiple imputation sensitivity analysis for missing data (<8% for all variables).
Findings: 64,344 subjects were included with median(IQR) age=9(4-15), 51% interfacility transfers, 2.04% mortality, 2.10% admission hypotension and 1.57% trauma bay transfusion rate. Overall, 46% of hypotensive patients, 42% of transfused patients, and 63% both hypotensive and transfused died. Hypotension (OR=12.8, 95%CI=10.65-15.36, p<0.001) and transfusion (OR=3.08, 95%CI=2.78-3.44, p<0.001) significantly increased odds of death after controlling for injury severity, penetrating and child abuse mechanisms, admission GCS, and age. Survival curves demonstrated worse survival for transfused patients in early(<24 hours), intermediate(24-120 hours), and late(>120 hours) time periods (all p<0.001).
Conclusions (implications for practice): Hypotension and trauma bay blood transfusion are poor prognostic indicators. These red flags should signal high acuity, and prompt immediate and aggressive resuscitation. Earlier recognition of shock and targeted interventions, including increased availability of blood products to prehospital providers, may facilitate timely hemostatic resuscitation, preventing circulatory collapse and secondary brain injury.
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