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Uncontrolled haemorrhage is a leading cause of early mortality in trauma. Administration of blood products, packed red cells and fresh frozen plasma (PRBC:FFP) in the ratio of 1:1 is associated with improved mortality in major haemorrhage in adult trauma. However, there is little evidence available for the management of major haemorrhage in the context of paediatric trauma.
We retrospectively analysed the local paediatric trauma database of all children following trauma call activation on arrival at the emergency department of The Royal London Hospital, a major urban trauma centre in London. The study period was over 15 months, May 2008 to August 2009. During this period, there has been no major haemorrhage policy within the centre for paediatric trauma. We collected data on demographic profile, injury severity scores, blood products transfused in the first 24 hours and the outcomes. We defined massive transfusion as the requirement of packed red cells >40 ml/kg in the first 4 hours or >80 ml/kg in the first 24 hours.
Two hundred and twenty-seven children presented to the emergency department during this period following major trauma call activation. The median age at presentation was 10.2 years. Thirteen (5.7%) children had major haemorrhage. The median ISS was 35 (IQR 10 to 60). All but one were males. Three had penetrating trauma, one of whom made it to theatre, but all died. Four had emergency damage control surgery. Abnormal results were seen in three patients, each having one abnormal result (INR = 1.9 and APTT = 86, low Hb = 7.6, thrombocytopaenia = 63). Eight of the 13 patients received additional blood products such as fresh frozen plasma, platelets and cryoprecipitate. However, no patient received the ratio of blood products of PRBC:FFP of 1:1 as practised in adult trauma. Two patients had no admission bloods done. Worsening coagulation parameters were seen in two patients when measured post transfusion and the remaining 11 patients did not have routine monitoring of blood parameters post transfusion. Eight (62%) patients died, of which seven died in the emergency department.
Major haemorrhage is associated with a very high mortality in severely injured children. We recommend rigorous monitoring of laboratory parameters to guide appropriate administration of blood products. There is a need for instituting a major haemorrhage policy in paediatric trauma and consideration of point-of-care testing of blood parameters.