Development of an algorithm for adjudicating actionable hemorrhage in pediatric trauma patients

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BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. LEVEL OF EVIDENCE: Diagnostic Test and Criteria; Level III.

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