Objectives & Background Major trauma in children, while being relatively uncommon, is still a principal cause of preventable death with severe haemorrhage being one of the main responsible reasons. ‘Major haemorrhage protocols’ (known in our institution as a ‘Code Red’) have been widely introduced in order to make large amounts of blood products available quickly. Most protocols, including the 'Code Red' involve adaptations for paediatrics. The ratio of blood products is 1:1 packed red blood cells (PRBCs) to Fresh Frozen Plasma (FFP) mirroring the adult literature that has evidence of improved outcomes.

The objective was to investigate the incidence, demographics, physiology and outcomes of the children triggering a ‘Code Red’ protocol.

Methods All ‘code red’ activations for children (all those ≤18 years) from 1st Jan 2010 to 31st Dec 2015 were identified then resuscitation room records and computer databases were scrutinised.

Results 1104 children presented during this period as 'trauma call' pre-alerts with only 36 children triggered the ‘Code Red’ protocol (3%). 31 actually received blood with 5 receiving products from prehospital teams.

The age distribution was unsurprisingly skewed towards older age groups (median 17 years, mean 15.4 years) and predominantly male 89%. Only 3 cases were under 12.

28 (78%) had penetrating trauma of which 4 were gun shot wounds.

4 arrived in traumatic cardiac arrest (100% mortality) and were given the most blood products. Of the other patients, only 25% were hypotensive and only 47% were tachycardic.

Low haemoglobin, deranged clotting or both were seen in 27 cases, with worsening coagulation in 13 patients post transfusion.

5 children (18%) of patients receiving more than one unit of PRBCs, had a 1:1* ratio of PRBC:FFP. *(permitted to be a difference of 1 unit only)

25 cases were taken direct to theatre with an overall mortality of 25%, with 2 deaths in the emergency department, 4 in theatre and 3 later in critical care.

Conclusion The most common paediatric case to trigger a major haemorrhage protocol at our intitution (72%) is a teenage male with penetrating trauma. 'Code Red' calls for smaller children or those sustaining blunt trauma are extremely rare.

The data supports the caution that vital signs are poor indicators of hypovolaemia and, despite the protocols, it is still difficult to ensure recommended ratios of blood to plasma are administered.