PEDIATRIC CONSIDERATIONS

- Critically wounded or ill pediatric patients are more difficult for the Role 1 provider or medic because of the lack of regular exposure to pediatric care. It is recommended that a pediatric reference card or Broselow tape be available to identify pediatric ranges for vital signs, drugs, and supplies.
- Total circulating blood volume in children can be estimated at 70–80mL/kg for children younger than age 12 years.31 In very young or small children, this is a very small volume. For example, an average 1-year-old American child weighs 10–11kg and has a total blood volume approximately equivalent to two units of blood. Underestimating blood loss percentage and over resuscitating should both be avoided.
- As in adults, do not hesitate to use an IO catheter as the first and primary line for initial resuscitation. A second IV or IO line should be started as soon as possible for additional drug administration.
- TXA is indicated in pediatric casualties. The dose is 15mg/kg TXA loading dose (maximum, 1g) over 10 minutes followed by 2mg/kg/h for 8 hours (maximum, 1g).33

To prepare the second dose as a drip, inject 15mg/kg TXA into a 100mL bag of NS. Using a dial-a-flow drip set, place the drip rate at 13 mL/h (OR by drip count: 1 drip every 5 seconds for 60 drip/mL tubing; 1 drip every 18 seconds for 15 drip/mL tubing; 1 drip every 27 seconds for 10 drip/mL tubing).

- Similar to adults, early transfusion therapy should be started sooner rather than later. LTOWB and FWB are both acceptable to give to children with life-threatening hemorrhage. There is no contraindication to the use of any WB product in children. The initial dose for blood is 10mL/kg, but in children with massive hemorrhage, blood products can be given in higher doses as fast as needed to gain hemodynamic stability. Massive transfusion in pediatrics has been defined as more than 40mL/kg of blood products in 24 hours. WB is easier to titrate effectively in children than component therapy.
- Children are at high risk of developing hypocalcemia, hypomagnesaemia, metabolic acidosis, hypoglycemia, hypothermia, and hyperkalemia during transfusion. Therefore, frequent monitoring (every hour if possible) and correction of acid/base status, electrolytes, and core temperature is indicated during the resuscitation of pediatric casualties, when available.