title: Massive transfusion in paediatric and adolescent trauma patients: incidence, patient profile, and outcomes prior to a massive transfusion protocol.
abstract: OBJECTIVE
  The purpose of this study was to quantify the incidence, patient profile, and outcomes associated with massive transfusion in paediatric trauma patients prior to establishing a massive transfusion protocol.
  
  
  METHODS
  We performed a retrospective review of paediatric trauma patients treated at London Heath Sciences Centre between January 1, 2006, and December 31, 2011. Inclusion criteria were Injury Severity Score (ISS) greater than 12 and age less than 18 years.
  
  
  RESULTS
  435 patients met the inclusion criteria. Three hundred and fifty-six (82%) did not receive packed red blood cells in the first 24h, 66 (15%) received a non-massive transfusion (<40mL/kg), and 13 (3%) received a massive transfusion (>40mL/kg). Coagulopathy of any kind was more common in massive transfusion (11/13; 85%) than non-massive (32/66; 49%) (p=0.037). Hyperkalemia (18% versus 23%; p=0.98) and hypocalcemia (41% versus 46%; p=1.00) were similar in both groups. Of the 13 massively transfused patients, 9 had multisystem injuries due to a motor vehicle collision, 3 had non-accidental head injuries requiring surgical evacuation, and 1 had multiple stab wounds. In the absence of a massive transfusion protocol, only 8 of the 13 patients received both fresh frozen plasma and platelets in the first 24h. Massive transfusion occurred in patients from across the age spectrum and was associated with severe injuries (mean ISS=33), a higher incidence of severe head injuries (92%), longer hospital stay (mean=36 days), and increased mortality (38%).
  
  
  CONCLUSIONS
  This study is the first to describe the incidence, complications, and outcomes associated with massive transfusion in paediatric trauma patients prior to a massive transfusion protocol. Massive transfusion occurred in 3% of patients and was associated with coagulopathy and poor outcomes. Protocols are needed to ensure that resuscitation occurs in a coordinated fashion and that patients are given appropriate amounts of fresh frozen plasma, platelets, and cryoprecipitate.
authors.affiliation: Division of General Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
authors.forename: Michael Hobbs
authors.initials: MH
authors.lastname: Livingston
authors.affiliation: Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.
authors.forename: Supriya
authors.initials: S
authors.lastname: Singh
authors.affiliation: Division of General Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada; Trauma Program, London Health Sciences Centre, London, Ontario, Canada. Electronic address: neil.merritt@lhsc.on.ca.
authors.forename: Neil Howard
authors.initials: NH
authors.lastname: Merritt
mesh_terms: D000293:Adolescent; D001778:Blood Coagulation Disorders / Q000401:mortality / Q000628:therapy*; D016913:Blood Component Transfusion / Q000379:methods* / Q000401:mortality; D002170:Canada / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D002985:Clinical Protocols; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006947:Hyperkalemia / Q000401:mortality*; D006996:Hypocalcemia / Q000401:mortality*; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009104:Multiple Trauma / Q000401:mortality / Q000628:therapy*; D010949:Plasma; D012151:Resuscitation / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D016019:Survival Analysis; D014193:Trauma Centers; D016896:Treatment Outcome
keywords: Coagulopathy; Paediatric; Transfusion; Trauma