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Too little too late

Hypotension and blood transfusion in the trauma bay are independent predictors of death in injured children

Leeper, Christine M., MD, MS; McKenna, Christine, MSN; Gaines, Barbara A., MD

Journal of Trauma and Acute Care Surgery: October 2018 - Volume 85 - Issue 4 - p 674–678
doi: 10.1097/TA.0000000000001823

BACKGROUND 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 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).

RESULTS Sixty-four thousand three hundred forty-four subjects were included with median (interquartile range) age, 9 years (4–15 years); 51% interfacility transfers; 2.0% mortality; 4.4% admission hypotension; and 1.6% trauma bay transfusion rate. Overall, 46% of hypotensive patients, 42% of transfused patients, and 63% both hypotensive and transfused died. Hypotension (odds ratio, 12.8; 95% confidence interval, 10.7–15.4; p < 0.001) and transfusion (odds ratio, 3.1; 95% confidence interval, 2.8–3.4; p < 0.001) significantly increased odds of death after controlling for injury severity, penetrating and child abuse mechanisms, admission Glasgow Coma Scale score, and age. Survival curves demonstrated worse survival for transfused patients in early (<24 hours), intermediate (1–5 days), and late (>5 days) periods (all p < 0.001).

CONCLUSION Hypotension and trauma bay blood transfusion are poor prognostic indicators. These events should signal high acuity and prompt immediate and aggressive resuscitation. Earlier recognition of shock and appropriate interventions, including increased availability of blood products to prehospital providers, may facilitate timely hemostatic resuscitation, preventing circulatory collapse and secondary brain injury.

LEVEL OF EVIDENCE Epidemiological, level III.

From the Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC (C.M.L., C.M., B.A.G.), Pittsburgh, Pennsylvania.

Submitted: November 27, 2017, Revised: January 19, 2018, Accepted: January 22, 2018, Published online: January 31, 2018.

This article was a podium presentation at the 4th Annual Meeting of the Pediatric Trauma Society, November 2–4, 2017, in Charleston, SC.

Address for reprints: Christine M. Leeper, MD, General Surgery Resident, Children’s Hospital of Pittsburgh of UPMC, 7th Floor, Faculty Pavilion, One Children's Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA 15224; email:

© 2018 Lippincott Williams & Wilkins, Inc.