Kim Mary S, Sippel Genevieve J, Sullivan Travis M, Alcasid Nathan J, Rodgers Steffanie J, Griffin Kristine L, Mun Aaron H, Gochi Andrea M, Jensen Aaron R, Leonard Julie C, Burd Randall S
From the Division of Trauma and Burn Surgery (M.S.K., G.J.S., T.M.S., A.H.M., R.S.B.), Children's National Hospital, Washington, DC; Division of Pediatric Surgery (N.J.A., A.M.G., A.R.J.), University of California San Francisco Benioff Children's Hospitals, San Francisco; Department of Surgery (N.J.A., A.M.G.), University of California, San Francisco, East Bay, Oakland, California; Division of Emergency Medicine (S.J.R., J.C.L.) and Division of Pediatric Surgery (K.L.G.), Nationwide Children's Hospital; Ohio State University College of Medicine (K.L.G., J.C.L.), Columbus, Ohio; and Department of Surgery (A.R.J.), University of California San Francisco, San Francisco, California.
J Trauma Acute Care Surg. 2025 Mar 3. doi: 10.1097/TA.0000000000004588.
Bleeding is the leading cause of preventable death in trauma. Early identification of hemorrhage improves patient outcomes. Current triage tools for predicting hemorrhage rely on transfusion receipt as a surrogate outcome, indicating that blood was needed. This outcome does not account for misclassification of patients who receive prompt hemorrhage control procedure (HCP) without transfusion, patients who die before transfusion receipt, or those who receive unnecessary transfusion. Objective criteria that do not rely on transfusion receipt alone are needed to more accurately determine actionable hemorrhage and the appropriateness of transfusions in pediatric trauma patients.
We defined actionable hemorrhage within 6 hours of emergency department arrival as (1) actual or (2) estimated pretransfusion hemoglobin <8 g/dL, (3) performance of an HCP irrespective of transfusion receipt, or (4) death within 24 hours with an autopsy supporting bleeding as the cause of death. We applied this algorithm to 4,371 children (younger than 18 years) treated for blunt or penetrating injuries at three level 1 pediatric trauma centers between 2019 and 2021.
A total of 4,201 children (96.1%) did not have actionable hemorrhage. One hundred sixty-four (3.8%) met the criteria for actionable hemorrhage, including 129 who were transfused within 6 hours. Transfusion receipt alone as an outcome missed 35 of 164 children (21.3%) with actionable hemorrhage: 19 who underwent an HCP and 16 with a hemoglobin level of <8 g/dL but not transfused within 6 hours. Thirty-eight of 167 children (22.8%) who received transfusion within 6 hours did not have actionable hemorrhage. Transfusion receipt as a test for actionable hemorrhage had a sensitivity of 78.7%, specificity of 99.1%, positive predictive value of 77.2%, negative predictive value of 99.2%, and Matthews correlation coefficient of 0.77.
Relying on transfusion receipt as a surrogate for actionable hemorrhage both underestimates and overestimates the actual need for intervention for hemorrhage. This study supports adjudicating actionable hemorrhage with a structured, criteria-based approach to more accurately ascertain this outcome.
Diagnostic Test and Criteria; Level III.
出血是创伤中可预防死亡的主要原因。早期识别出血可改善患者预后。当前用于预测出血的分诊工具依赖输血情况作为替代结局，表明需要输血。该结局未考虑那些接受了及时的出血控制程序（HCP）但未输血的患者、在输血前死亡的患者或接受不必要输血的患者的错误分类情况。需要不单纯依赖输血情况的客观标准来更准确地确定小儿创伤患者中可采取行动的出血情况及输血的适宜性。
我们将急诊科就诊后6小时内可采取行动的出血定义为：（1）实际出血或（2）输血前估计血红蛋白<8 g/dL，（3）无论是否输血均实施了HCP，或（4）24小时内死亡且尸检支持出血为死因。我们将该算法应用于2019年至2021年间在三个一级小儿创伤中心接受钝性或穿透性损伤治疗的4371名儿童（18岁以下）。
共有4201名儿童（96.1%）没有可采取行动的出血情况。164名（3.8%）符合可采取行动的出血标准，其中129名在6小时内接受了输血。仅将输血情况作为结局遗漏了164名有可采取行动出血情况儿童中的35名（21.3%）：19名接受了HCP，16名血红蛋白水平<8 g/dL但在6小时内未输血。在6小时内接受输血的167名儿童中有38名（22.8%）没有可采取行动的出血情况。将输血情况作为可采取行动出血情况的检测方法，其敏感性为78.7%，特异性为99.1%，阳性预测值为77.2%，阴性预测值为99.2%，马修斯相关系数为0.77。
依赖输血情况作为可采取行动出血情况的替代指标会低估和高估实际的出血干预需求。本研究支持采用基于标准的结构化方法来判定可采取行动的出血情况，以更准确地确定这一结局。
诊断试验和标准；三级。
