Prehospital Whole Blood Resuscitation in Pediatric Patients: A San Antonio Cohort Descriptive

OBJECTIVES: The objective of this study is to describe the demographic, clinical, and prehospital care characteristics of pediatric patients receiving whole blood (WB) resuscitation by San Antonio Fire Department (SAFD). METHODS: We conducted an observational retrospective cohort study to evaluate pediatric patients who received prehospital low-titer group O positive WB transfusion through the SAFD prehospital blood program between October 2018 and June 2025. The objective was to characterize patient demographics, injury patterns, resuscitative interventions, shock physiology, and outcomes among pediatric recipients in a mature civilian emergency medical services WB program. RESULTS: Of 1703 WB transfusions, 73 (4.3%) were pediatric. Most patients were male (76%), age range 1-17 years old with a mode of 17 years, adolescents represented 78%. Trauma accounted for 96% of cases, firearm injury (74%); all penetrating (84%), blunt (12%), with the remainder classified as medical/unknown. Vascular access was intravenous (73%), intraosseous (26%). Tranexamic acid was co-administered in 39%; 12% received ceftriaxone. When analyzed using age-adjusted Shock Index Pediatric Age-Adjusted (SIPA) thresholds (>1.2 for 1-6 years, >1.0 for 7-12 years, and >0.9 for 13-17 years), based on the initial available prehospital heart rate and systolic blood pressure, 45% of patients had an elevated SIPA, 22% had a normal SIPA, 20% were pulseless and therefore could not undergo SIPA calculation, and 14% lacked sufficient vital-sign data for classification. Survival was 50%; died 39%, and unknown outcomes 11%. Mean delta shock index values were most negative in toddlers (1-4 years) -0.97 ± 1.29, followed by children (5-11 years) -0.76 ± 1.07 and adolescents (12-17 years) -0.16 ± 0.46, indicating a greater physiologic response to resuscitation among younger pediatric patients. CONCLUSIONS: Pediatric WB recipients were predominantly adolescent males who sustained penetrating trauma and presented with moderate-to-severe shock. Younger age groups had larger descriptive decreases in shock index during the prehospital encounter; however, these findings should be interpreted cautiously given the small subgroup sizes and observational design.