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Recognizing Life-Threatening Bleeding In Pediatric Trauma: A Standard For When To Activate Massive Transfusion Protocol
Katrina M Morgan1, *Barbara A Gaines2, *Ward M Richardson2, Stephen Strotmeyer2, *Christine M Leeper1
1University of Pittsburgh Medical Center, Pittsburgh, PA;2Children's Hospital of Pittsburgh, Pittsburgh, PA

Background (issue): Delays in activating massive transfusion is associated with increased mortality in trauma. Superior compensatory mechanisms in children make it challenging to identify life-threatening hemorrhage. There is no accepted clinical threshold in children for activating massive transfusion protocols (MTP).
Methods: Children 0-17 years old who received ≥ 1 transfusion in the first 24 hours after injury from 2010-2019 were included. The time and total number of blood products administered (whole blood, red blood cells, plasma or platelets) was recorded. The greatest number of products transfused within one hour was calculated. Youden’s index determined the cut point for the number of products that maximized sensitivity and specificity to predict in-hospital mortality, need for urgent surgery, and second life-threatening bleeding episode.
Findings: 287 patients were included in the study. The median(IQR) age was 6(2-13) years and 60% were males. 70% suffered from blunt trauma, and median(IQR) Injury Severity Score (ISS) was 26(17-35). The optimal cutoff point to define massive rapid transfusion was >2 units (20 mL/kg) of product; this same cutoff optimized test characteristics for mortality (sensitivity=70%, specificity=77%), need for urgent surgery (sens=51%, spec=73%) and second bleeding episode (sens=77%, spec=74%). For every unit of product administered, there was a 10% increased risk of mortality (OR=1.1, p<0.001).
Conclusions (implications for practice): Transfusion of more than 2 blood products within an hour should be used as a threshold for activating massive transfusion protocols in children. Children receiving more than 2 units of any product are at high risk of mortality; this population may benefit from more timely and aggressive product resuscitation.


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