Prehospital Risk Stratification for Early Transfusion in Pediatric Trauma: A National Trauma Data Bank Analysis

Pediatric criteria remain limited for identifying injured children who may benefit from early blood transfusion for hemorrhagic shock. This study evaluated whether emergency medical services (EMS)-observable variables in a national trauma registry could identify children at risk for early hospital blood transfusion.

We conducted an observational retrospective cohort study using the National Trauma Data Bank (2017-2020). Among 391,126 records for patients aged 1-15 years, we included children transported by EMS directly from the scene to a participating trauma center after excluding burn injuries, interfacility transfers, and missing pre-identified EMS variables (systolic blood pressure, heart rate, or Glasgow Coma Scale [GCS]). The primary outcome was any blood product administered within 4 hours of emergency department arrival. Five prespecified EMS-observable predictors composed the model: age-adjusted hypotension, age-adjusted tachycardia, GCS ≤14, penetrating mechanism, and prehospital traumatic cardiac arrest. We fit a multivariable logistic regression and a classification and regression tree (CART) using an 80/20 stratified train-validation split. Missing data sensitivity analyses included multiple imputation and CART refitting in the broader eligible cohort.

Among 79,764 children, 2,634 (3.3%) received early transfusion in the hospital. All five predictors were independently associated with early transfusion, led by GCS ≤14 (adjusted odds ratio [aOR] 8.38; 95% confidence interval [CI], 7.61-9.22), penetrating mechanism (aOR 5.87; 95% CI, 5.28-6.51), and age-adjusted hypotension (aOR 5.39; 95% CI, 4.74-6.13). In the validation cohort, CART analysis stratified patients into low-, intermediate-, and high-risk tiers comprising 77.0%, 19.7%, and 3.3% of patients, respectively. Early-transfusion rates were 1.2%, 6.1%, and 36.7% across these tiers. The high-risk tier accounted for 36.8% of all early transfusion events. Using the high-risk tier as a decision threshold, sensitivity was 36.8%, specificity 97.8%, positive predictive value 36.7%, and negative predictive value 97.8%.

Five EMS-observable features, including age-adjusted hypotension, age-adjusted tachycardia, GCS ≤14, penetrating mechanism, and prehospital traumatic cardiac arrest, identified a small subgroup of pediatric trauma patients with substantially elevated risk of early hospital transfusion. This parsimonious framework may inform prospective validation of prehospital transfusion criteria.