Prehospital Blood Administration in Pediatric Patients: A Case Report

Abstract Prehospital blood administration programs have demonstrated success both on the battlefield and throughout civilian emergency medical services programs. While previous research often discusses the use of prehospital blood administration for adult trauma and medical patients, few studies have reported the benefits of prehospital blood administration for pediatric patients. This case report describes treatment received by a 7-year-old female gunshot victim who was successfully treated by a prehospital blood administration program in the southern United States.


Introduction
Trauma has long been recognized as a leading cause of preventable death in the United States, especially in young healthy populations (1,2). Accordingly, a growing body of evidence has suggested that administration of prehospital blood products can improve outcomes in patients suffering from hemorrhagic shock after traumatic injuries. This finding is especially important when prolonged transport intervals are encountered. For example, Pusateri et al. found prehospital plasma administration beneficial when ambulance transport intervals were 20 minutes or longer (3), and Powell et al. demonstrated that receiving blood products as little as 10 minutes sooner can generate a marked difference in survivability for trauma patients (4). Other studies have elucidated the role of prehospital blood products in hemodynamic stabilization (5) and trauma-induced coagulopathy (6) prior to emergency department arrival (5), with concomitant increases in survival. Data this compelling has encouraged increasing use of prehospital blood products by emergency medical services (EMS) programs across the country (6).
While the use of prehospital blood products has proven efficacious in numerous studies, a large gap in data exists where pediatric patients are concerned. One study reported coagulopathy in 77% of pediatric trauma victims and found coagulopathic patients incurred significantly worse outcomes compared to non-coagulopathic patients (7). Whereas several studies have discussed the use of prehospital blood products in pediatric populations (8)(9)(10), only one described implementation during EMS ground transport (11). With rates of pediatric trauma, especially in the form of gunshot injury, ever on the rise (12), it has become more important than ever to identify all safe and effective interventions to optimize outcomes for the pediatric demographic. In this report, we present a case in which administration of prehospital blood proved lifesaving in the resuscitation a pediatric patient with a gunshot wound to the upper chest who faced prolonged transport to the nearest trauma center. The patient's guardian provided written consent to allow this patient to be included in this case report, which was reviewed and deemed non-human subjects research by the Prisma Health institutional review board.

Setting
Prisma Health Ambulance Services has been the sole EMS provider in Oconee County, South Carolina since 1966, covering 674 square miles and a population of approximately 76,500. The closest Level I trauma center is approximately 40 miles away by ground EMS. Prisma Health Ambulance Services provides 9-1-1, inter-facility, critical care, and nonemergent transport for Oconee County and Oconee Memorial Hospital. This agency employs 98 EMS personnel and covers Oconee County with seven advanced life support (ALS) ambulances, two basic life support ambulances, and two ALS supervisor quick-response vehicles. Prisma Health Ambulance Services was dispatched to 13,056 9-1-1 calls in 2022. ALS paramedic supervisors were dispatched to 2,397 9-1-1 calls, 17 of which involved activation of the prehospital blood administration protocol.

Prehospital Blood Administration Protocol
In February of 2020 Prisma Health Ambulance Services obtained permission from the South Carolina Department of Health and Environmental Control to start pilot trial for prehospital blood administration. Individuals aged 6 years and above are eligible for the administration of blood products if they present with signs of massive hemorrhage, traumatic injury (penetrating or blunt), suspected dissecting/rupturing aneurysm (abdominal or thoracic), gastrointestinal bleeding, or signs of intra-abdominal bleeding. The age limit was restricted to 6 years of age and above as physicians in charge of the Prisma Health pediatric trauma unit felt individuals age 6 and above could safely receive a full unit of blood.
Blood products for the prehospital blood administration program are carried by ALS supervisors on quick-response vehicles. The program carries O negative packed red blood cells (PRBC) and AB fresh frozen plasma (FFP). Temperature is regulated by storage in a Credo cube insert within a cooler, which maintains the blood products at a temperature of approximately 2.0-4.5 degrees Celsius (Figures 1 and 2). Temperatures are monitored every 8 hours and recorded in a log maintained by ALS supervisors ( Figure 3). Blood products are exchanged every 24 hours at the start of shift. ALS supervisors report to the blood bank located in Oconee Memorial Hospital at 06:30 to perform the exchange. Blood bank personnel open the sealed bag, remove the remaining blood products and data logger, check the type/lot/expiration dates and new data log, then place new blood products and a data logger into the Credo cube. The crew then returns to base where the old Credo cube is placed into the freezer, and the crew places the Credo cube insert containing the blood products into a new cube.
ALS supervisors equipped with the blood products are dispatched with a transport unit to all incidents that may meet eligibility criteria for the prehospital administration protocol. A soft carry bag accompanies each blood cooler containing a Quantum Fluid Warmer and the specialized blood warming tubing. If blood is indicated, all clinicians initiate the blood checklist (Appendix 1) and administer blood products in accordance with the Prisma Health protocol (Appendix 2). Pediatric patients, defined as individuals > 5 and < 12 years old or < 55 kg, are administered 10 ml/ kg of O negative PRBC and FFP, which may be repeated once. Additional information about the blood administration protocol is included in Appendix 2.

Case Report
A 7-year-old female with no pertinent medical history was the victim of an accidental shooting in a remote area approximately 68 miles from the nearest trauma center. The bullet was a full metal jacket fired at close range. The 9-1-1 call was received, and emergency medical dispatch was provided at 15:26. A paramedic ambulance, two supervisor paramedic quick response vehicles equipped with blood products, and an air medical helicopter were dispatched at 15:28. Paramedics arrived within 7 minutes of the initial 9-1-1 call at 15:34. The patient presented supine on the ground with a Glasgow Coma Scale of 6 (eyes 1, verbal 1, motor 4). Rapid trauma assessment showed a wound to the left anterior chest lateral to the sternum between the first and second intercostal spaces midclavicular, with bruising and burns around the wound. Her skin was profoundly cyanotic, cool, and dry. Initial vital signs taken at 15:39 were blood pressure 86/61 mmHg, heart rate 135 per minute, respiratory rate 35 breaths per minute and shallow, and oxygen saturation 58% on room air. Commercial vented chest seals were applied to both wounds. A capnography nasal cannula at 10 liters of oxygen per minute was applied under the mask of a bag valve and her ventilations were assisted by paramedics with a bag-valve-mask. Intravenous access was initiated in the right accessory cephalic vein at 15   access. Vital signs after infusion of two units of blood products and 20 mcg of push-dose epinephrine were blood pressure 90/50 mmHg, heart rate 153 per minute, respirations assisted with BVM at 30 per minute, oxygen saturation 78% on 15 liters per minute, and end tidal capnography 11 mmHg. Upon arrival of the air medical crew at 15:54 interosseous access was established in the left proximal tibia and the patient was sedated and paralyzed with 25 mg of ketamine and 50 mg of rocuronium. Intubation with a size 6.0 endotracheal tube was successful on the first attempt. Her vital signs upon loading into the helicopter were blood pressure 105/67 mmHg, heart rate 148 per minute, respirations assisted at 30 per minute, oxygen saturation 78% on 10 liters per minute, and end tidal capnography 45 mmHg. After an 18-minute flight, she arrived at the trauma bay at 16:39, with blood pressure 105/56 mmHg, heart rate 172 per minute, and oxygen saturation 96% on 15 liters oxygen. Chest x-ray identified a left hemothorax and a chest tube was placed with an immediate output of 500 ml of blood. She was brought emergently to the operating room at 17:17 for an exploratory left thoracotomy. In the operating room, surgeons identified the wound to the left anterior chest as well as another wound to her left upper back near the superior aspect of her left clavicle. A clamshell thoracotomy was performed with discovery of a lacerated left subclavian vein. Both wounds were adjacent to the mediastinum. She required aggressive resuscitative measures including a massive transfusions of blood products and after cardiac arrest, a period of open cardiac massage. The 1 cm laceration to the subclavian was repaired and the gunshot wounds closed. She was brought back to the operating room the following day and her chest was completely closed. Six days after the shooting she was extubated and able to communicate with her caregivers. Eleven days after the accident she was discharged without any neurological or physical deficits.

Discussion
This case report affirms the benefits of prehospital blood administration for pediatric patients, responsible in this case for saving the life of a 7-year-old child in the rural southern United States.
While there are many examples of prehospital blood transfusion programs in the United States (13), very few describe the administration of blood products to pediatric populations. For example, a 2019 scoping review of prehospital blood administration programs throughout the world showed only 7 (12.3%) of 57 articles detailing civilian programs that included criteria for prehospital blood transfusions in children (13). Of those, only one described a prehospital blood administration program primarily involving ground EMS, which only reported results on adult patients (ages 16-91) who participated in the program within the first 2 months (11). Further, this program, like many programs included in the literature, occurred in an urban EMS system where additional resources are often more plentiful compared to those available to rural agencies. Taken together, this case is unique to previous literature in that it not only describes the successful prehospital administration of blood products to a pediatric patient, but also demonstrates how pediatric populations can be incorporated into a prehospital blood administration protocol initiated by ground EMS in the rural United States.
Another unique aspect of this patient case was the geographic distance from a Level I trauma center, which would typically cause a delay in receiving blood products. Crandall et al. established an adverse relationship between distance from a trauma center and survivability of traumatic injuries, going so far as to refer to these locations without access as "trauma deserts" (14). The same study also determined that sustaining a gunshot wound more than 5 miles from a trauma center is correlated with a significantly increased risk of death. Similarly, military studies have shown the importance of early blood product administration in increasing survivability after massive hemorrhage when faced with prolonged patient transport intervals due to austere location (15), highlighting the importance of immediate initiation of blood products. In the current case, ground EMS personnel were able to transfuse blood products within 5 minutes of arrival at the scene. This well-established protocol allowed immediate transfusion without waiting 20 minutes for the arrival of helicopter EMS or incurring potential delays reaching direct medical oversight. Considering the rural location of the patient in this case, a greater emphasis had to be placed on providing excellent prehospital resuscitative efforts since definitive care was not nearby. The current case should encourage EMS agencies with prehospital blood administration programs to ensure protocols include instructions for providing pediatric patients blood products to limit delays for transfusion initiation.
Trauma resuscitation doctrine has undergone profound changes in recent years. Prehospital blood products have become an important mainstay in trauma resuscitation due to their ability to maintain adequate perfusion, properly deliver oxygen to tissues, and reduce the dangerous coagulopathy that often results from crystalloid or colloid fluid resuscitation (16)(17)(18). The ensuing hypothermia, coagulopathy, and acidosis that follows non-blood product resuscitation is often referred to as the "lethal triad" and greatly contributes to the significant morbidity and mortality associated with traumatic injury (19). Prompt introduction of blood products can mitigate the deleterious effects of hemorrhagic injury.
Administration of blood to pediatric patients, although potentially lifesaving, is not risk-free. Children have the same risks as adults with transfusion, such as infection (e.g., human immunodeficiency virus, hepatitis C, hepatitis B), acute hemolytic reaction (usually due to clerical error), delayed hemolytic reaction, febrile reaction, allergic reaction, transfusion-related acute lung injury, transfusion-associated circulatory overload, and hypocalcemia. One study in a trauma center showed pediatric patients exhibit more complications with blood transfusions than matched adults, ranging from metabolic alkalosis to hyperkalemia to transfusion-related lung injury (20). The exact mechanism behind this greater incidence of complications is largely unknown but is generally thought to be due to a pediatric patient's lack of fully developed physiological compensatory mechanisms. The potential for adverse outcomes due to overload of prehospital blood products underscores the necessity of weight-based transfusion guidelines, such as the 10 mg/kg guideline of the current study. Yet, few studies have reported adverse outcomes due to prehospital pediatric blood transfusion, with many considering it safe and useful in pediatric trauma patients (21,22). Although overall rates of serious complications associated with transfusion are still low, the risks cannot be ignored, and proper safeguards such as weight-based transfusion guidelines must be put in place before committing to protocols that call for the use of this intervention outside the relative safeguards of a hospital setting. Appendix 2 under the Blood Administration Protocol 10.2 -Pearls describes the activities that this service uses for potential reactions.
This case report demonstrates an exemplary implementation of an EMS system's prehospital blood products program in the context of treating a pediatric patient. It highlights the synergistic effects of a coordinated, multi-tiered response system that employed blood as a part of its resuscitation protocol, and how the combined treatment elements contributed to the excellent outcome despite the patient's distance from definitive care. This case showcases the lifesaving potential of a prehospital blood products program, and shows that protocols can be tailored to accommodate the needs of a pediatric population.

Conclusions
This case highlights the importance of out-of-hospital care in the continuum of emergency and traumatic care, and the importance of having the correct tools available to optimize patient outcomes. It highlights the use of prehospital blood in a pediatric patient with a gunshot wound to the chest who had an excellent recovery, which the treating trauma team attributed to the availability of prehospital blood products.