Existing data on pediatric massive transfusion as part of trauma resuscitation is limited. We report the characteristics of pediatric casualties associated with undergoing massive transfusion at US ...military treatment facilities during combat operations in Iraq and Afghanistan.
We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by Centers for Disease Control age groupings: <1, 1–4, 5–9, 10–14, and 15–17 years. We defined a massive transfusion as 40 mL/kg of total blood products or more.
From January 2007 through January 2016 there were 3439 pediatric casualties within the registry, of which 543 (15.7%) met criteria for receiving a massive transfusion. The median age of children undergoing massive transfusion was 9 years (IQR 5–12), male (73.4%), injured in Afghanistan (69.9%) and injured by explosives (60.4%). Compared to other pediatric casualties, subjects undergoing massive transfusion had higher composite injury severity scores (median 17 versus 9), higher incidence of tachycardia (86.8% versus 70.9%), increased incidence of hypotension (31.2% versus 7.5%), and decreased survival to hospital discharge (82.6% versus 91.6%). Specific to body regions, casualties undergoing massive transfusion more frequently had serious injuries to the head/neck (30.0% versus 22.8%), the thorax (22.8% versus 9.9%), abdomen (26.8% versus 6.9%), the extremities (42.1% versus 14.6%), while less frequently had serious injuries to the skin (5.3% versus 8.4%). All findings were significant.
Further research is needed to better translate the lessons learned from pediatric trauma care in the combat setting into the civilian setting in developed countries.
Level of evidence: 3
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Opioids carry high risk of dependence, and patients can rapidly build tolerance after repetitive dosing. Low-dose ketamine is an analgesic agent alternative that provides more hemodynamic stability. ...We sought to describe the effects of prolonged ketamine use in non-burn patients.
We queried the electronic health system at the Brooke Army Medical Center for patient encounters with ketamine infusions lasting >72 hours. We abstracted data describing demographics, vital signs, ketamine infusion dose and duration, and discharge diagnoses potentially relevant to ketamine side effects.
We identified 194 subjects who met the study inclusion criteria. The median age was 39 years, most were male (67.0%), and most were primarily admitted for a non-trauma reason (59.2%). The mean ketamine drip strength was 43.9 mg/h (95% CI, 36.7-51.1; range 0.1-341.6) and the mean drip length was 130.8 hours (95% CI, 120.3-141.2; range 71-493). Most subjects underwent mechanical ventilation (56.1%) at some point during the infusion and most survived to hospital discharge (83.5%). On a per-day basis, the average heart rate was 93 beats per minute, systolic blood pressure was 128 mmHg, diastolic blood pressure was 71 mmHg, oxygen saturation was 96%, and respiratory rate was 22 respirations per minute.
We demonstrate that continuous ketamine infusions provide a useful adjunct for analgesia and/or sedation. Further development of this adjunct modality may serve as an alternative agent to opioids.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Abstract
Background
The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but ...pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM.
Methods
A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal (<31 days), infant (31-364 days), young children (1 to <8 years), and older children (8-17 years).
Results
During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates.
Conclusions
Within TRAC2ES, nearly one in six encounters were patients aged <18 years, with neonates or infants representing nearly one of three pediatric encounters. Slightly more than one in six pediatric patients required intubation for transport. The data suggest the need for appropriately trained transport teams and equipment be provided to support these missions.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Hemorrhage is one of the leading causes of preventable death in both military and civilian trauma. Implementation of items such as tourniquets and hemostatic dressings are helpful in controlling ...hemorrhage and increasing the survival rate of casualties when such injuries occur. Prehospital blood transfusions are used to treat patients with severe injuries where the standard methods of hemorrhage control are not an effective form of treatment. There is limited research and no widely accepted protocol on pediatric prehospital blood transfusions.
We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to U.S. and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties that received blood products prehospital.
From January 2007 through January 2016 there were 3439 pediatric casualties within the registry. Within this group, 22 casualties that received one or more blood product prehospital were identified. Children in the 10-14 years age (40%) group made up the largest proportion, 86% were male, almost all were injured by explosive (63%) or firearm (27%), and 77% survived to hospital discharge. The most frequently administered blood product was packed red cells (n = 17). Of the 22, 15 underwent massive transfusion within the first 24 hours of admission.
Prehospital administration of blood products occurred infrequently within this pediatric dataset, but those that received blood were critically injured with most receiving a massive transfusion. Given the frequency with which medical personnel are carrying blood products in the prehospital, combat setting, guidelines specific to pediatric administration would be beneficial.
Heat stress followed by an accompanying hemorrhagic challenge may influence hemostasis. We tested the hypothesis that hemostatic responses would be increased by passive heat stress, as well as ...exercise-induced heat stress, each with accompanying central hypovolemia to simulate a hemorrhagic insult. In aim 1, subjects were exposed to passive heating or normothermic time control, each followed by progressive lower-body negative pressure (LBNP) to presyncope. In aim 2 subjects exercised in hyperthermic environmental conditions, with and without accompanying dehydration, each also followed by progressive LBNP to presyncope. At baseline, pre-LBNP, and post-LBNP (<1, 30, and 60 min), hemostatic activity of venous blood was evaluated by plasma markers of hemostasis and thrombelastography. For aim 1, both hyperthermic and normothermic LBNP (H-LBNP and N-LBNP, respectively) resulted in higher levels of factor V, factor VIII, and von Willebrand factor antigen compared with the time control trial (all P < 0.05), but these responses were temperature independent. Hyperthermia increased fibrinolysis clot lysis 30 min after the maximal amplitude reflecting clot strength (LY
) to 5.1% post-LBNP compared with 1.5% (time control) and 2.7% in N-LBNP ( P = 0.05 for main effect). Hyperthermia also potentiated increased platelet counts post-LBNP as follows: 274 K/µl for H-LBNP, 246 K/µl for N-LBNP, and 196 K/µl for time control ( P < 0.05 for the interaction). For aim 2, hydration status associated with exercise in the heat did not affect the hemostatic activity, but fibrinolysis (LY
) was increased to 6-10% when subjects were dehydrated compared with an increase to 2-4% when hydrated ( P = 0.05 for treatment). Central hypovolemia via LBNP is a primary driver of hemostasis compared with hyperthermia and dehydration effects. However, hyperthermia does induce significant thrombocytosis and by itself causes an increase in clot lysis. Dehydration associated with exercise-induced heat stress increases clot lysis but does not affect exercise-activated or subsequent hypovolemia-activated hemostasis in hyperthermic humans. Clinical implications of these findings are that quickly restoring a hemorrhaging hypovolemic trauma patient with cold noncoagulant fluids (crystalloids) can have serious deleterious effects on the body's innate ability to form essential clots, and several factors can increase clot lysis, which should therefore be closely monitored.
ABSTRACT
Background
Evidence from military populations showed that resuscitation using whole blood (WB), as opposed to component therapies, may provide additional survival benefits to traumatically ...injured patients. However, there is a paucity of data available for the use of WB in uninjured patients requiring transfusion. We sought to describe the use of WB in non-trauma patients at Brooke Army Medical Center (BAMC).
Materials and Methods
Between January and December 2019, the BAMC ClinComp electronic medical record system was reviewed for all patients admitted to the hospital who received at least one unit of WB during this time period. Patients were sorted based on their primary admission diagnosis. Patients with a primary trauma-based admission were excluded.
Results
One hundred patients were identified who received at least one unit of WB with a primary non-trauma admission diagnosis. Patients, on average, received 1,064 mL (750–2,458 mL) of WB but received higher volumes of component therapy. Obstetric/gynecologic (OBGYN) indications represented the largest percentage of non-trauma patients who received WB (23%), followed by hematologic/oncologic indications (16%).
Conclusion
In this retrospective study, WB was most commonly used for OBGYN-associated bleeding. As WB becomes more widespread across the USA for use in traumatically injured patients, it is likely that WB will be more commonly used for non-trauma patients. More outcome data are required to safely expand the indications for WB use beyond trauma.
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DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK, VSZLJ
In adults with traumatic brain injuries (TBI), hypotension and hypertension at presentation are associated with mortality. The effect of age-adjusted blood pressure in children with TBI has been ...insufficiently studied. We sought to determine if age-adjusted hypertension in children with severe TBI is associated with mortality.
This was a retrospective analysis of the Department of Defense Trauma Registry (DoDTR) between 2001 and 2013. We included for analysis patients <18 years with severe TBI defined as Abbreviated Injury Severity (AIS) scores of the head ≥3. We defined hypertension as moderate for systolic blood pressures (SBP) between the 95
and 99
percentile for age and gender and severe if greater than the 99th percentile. Hypotension was defined as SBP <90 mmHg for children >10 years or < 70mmHg + (2 × age) for children ≤10 years. We performed multivariable logistic regression and Cox regression to determine if BP categories were associated with mortality.
Of 4,990 children included in the DoDTR, 740 met criteria for analysis. Fifty patients (6.8%) were hypotensive upon arrival to the ED, 385 (52.0%) were normotensive, 115 (15.5%) had moderate hypertension, and 190 (25.7%) had severe hypertension. When compared to normotensive patients, moderate and severe hypertension patients had similar Injury Severity Scores, similar AIS head scores, and similar frequencies of neurosurgical procedures. Multivariable logistic regression demonstrated that hypotension (odd ratio OR 2.85, 95 confidence interval CI 1.26-6.47) and severe hypertension (OR 2.58, 95 CI 1.32-5.03) were associated with increased 24-hour mortality. Neither hypotension (Hazard ratio (HR) 1.52, 95 CI 0.74-3.11) nor severe hypertension (HR 1.65, 95 CI 0.65-2.30) was associated with time to mortality.
Pediatric age-adjusted hypertension is frequent after severe TBI. Severe hypertension is strongly associated with 24-hour mortality. Pediatric age-adjusted blood pressure needs to be further evaluated as a critical marker of early mortality.
Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this ...evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system.
The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood, plasma, and platelets (PLT) given in the first 24 hours were calculated per kilogram body weight. Tranexamic acid use was also determined. Patients were divided into Early (2001-2005) and Late (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. Intensive care unit and hospital length of stay and 24-hour and in-hospital mortality rates were compared.
A total of 4,358 patients met inclusion criteria. Comparing Early versus Late, injuries from explosions, isolated or predominant head injuries, and injury severity score all increased. The proportion of TX+ patients also increased significantly (13.6% vs 37.4%, p < 0.001) as did the number of MT+ patients (2.1% vs 15.5%, p < 0.001). Transfusion of high plasma:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall, PLT and whole blood use was low. After adjusting for differences between groups, the odds of death was no different Early versus Late but decreased significantly in the MT+ patients with time as a continuous variable.
Transfusion practice in pediatric combat casualty care shifted toward a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries, and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children.
Epidemiologic study, level IV.
Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust ...shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting.
We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9).
From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87.
Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.
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