Consensus Guidelines for Prehospital Transfusion in Children: A Modified Delphi Study

OBJECTIVES: Hemorrhagic shock is a leading cause of early trauma-related mortality in children, yet implementation of prehospital blood transfusion (PHT) in children is heterogenous and without consistent guidance. Limited pediatric-specific evidence and physiologic differences from adults have contributed to substantial variability among existing emergency medical services (EMS) protocols. The objective of this study was to develop expert consensus recommendations for identifying pediatric patients who may benefit from PHT. METHODS: We conducted a modified Delphi consensus study using a multidisciplinary panel of 20 experts in pediatric surgery, pediatric emergency medicine, and EMS medicine. Investigators compiled candidate criteria from existing PHT protocols and expert input. We conducted iterative electronic surveys to achieve expert consensus. We predefined consensus thresholds as ≥80% agreement for inclusion and <50% for exclusion. We employed descriptive statistics to summarize responses across rounds. RESULTS: The panel evaluated 208 candidate items and accepted 35 recommendations for inclusion over six rounds of voting. Consensus defined eligibility for PHT in children consisting of 1) known or suspected severe hemorrhage or major blood loss; and 2) at least one indicator of shock following first-line hemorrhage control, and 3) EMS clinical judgment of the need for transfusion. Shock indicators included physiologic compromise, hemodynamic instability, poor perfusion, low cardiac output, or an abnormal validated pediatric shock index. Contraindications included do not resuscitate orders prohibiting transfusion and non-hemorrhagic shock. We were unable to reach consensus on routine inclusion of end-tidal carbon dioxide as an indication for transfusion. CONCLUSIONS: Experts came to consensus on pediatric-focused, pragmatic criteria to guide prehospital blood product transfusion in children. Implementation of these recommendations may reduce practice variability, support protocol development, and inform future prospective validation studies.