There are no prospective studies of transfusion resuscitation in pediatric trauma. Most major children’s centers extrapolate from adult literature and are using similar damage control resuscitation strategies in major hemorrhage. There are currently no data determining which patients may benefit from these strategies. See Appendix A for a suggested MT Protocol.

For children under a weight of 30 Kilograms (KG), transfusions of RBC units, FFP, or apheresis platelets should be given in “units” of 10-15 ml/kg. One unit of cryoprecipitate is typically administered for every 10 kg of body weight. Blood volume in children can be estimated at between 60-80ml/kg. Bear in mind that a “trauma pack” containing 6 U RBCs + 6 U FFP + 1 U apheresis platelets will deliver between 3000-4000ml of intravascular volume. A child of 30kg may have a TOTAL blood volume of 1800-2400ml. Over-resuscitation contributes to morbidity and mortality. It may be more convenient and safe to resuscitate children with WB since this product delivers full oxygen delivery and hemostatic functionality and may support more accurate volume dosing. For example, a typical unit of whole blood contains about 500-600ml (depending on bag type and volume: 450 or 500ml blood volume plus anticoagulant). For a severely injured, shocked child, a quarter to a half of a WB unit may provide adequate initial resuscitation, which can then be further titrated.

Pediatric approved Intraosseous (IO) devices can be used for transfusion if required. Note that sternal IOs designed for adults may pierce a child’s sternum and deliver fluids or blood products into the mediastinum.

A MT in pediatrics has been defined as ≥40ml/kg of blood products in 24 hours.1 The circulating blood volume in children is approximately 60-80 ml/kg. Children are at high risk of developing hypocalcemia, hypomagnesemia, metabolic acidosis, hypoglycemia, hypothermia and hyperkalemia during MTs. Therefore, frequent monitoring and correction of acid/base status, electrolytes, and core temperature is essential during the resuscitation of pediatric casualties. An approved blood warmer and other transdermal temperature management system devices are recommended for the prevention and treatment of hypothermia.

Although there are limited retrospective data demonstrating the benefit of TXA in pediatric trauma,2 there are studies of TXA use in pediatric cardiac, orthopedic and cranial surgeries showing overall safety and decreased transfusion requirements.3-6 There is no prospectively validated dosing available for pediatric trauma but loading doses of 10-100 mg/kg IV followed by 5-10 mg/kg/hour infusion doses are commonly used in elective surgery. The UK Royal College of Pediatrics and Child Health has recommended a loading dose of 15mg/kg (up to 1 gm) followed by 2mg/kg/hr over 8 hours (or up to 1gm over 8 hours). This regimen reflects standard adult dosing in trauma.7

Viscoelastic clot testing (e.g., TEG or ROTEM®) can be utilized to direct transfusion requirements as in adults utilizing the same thresholds discussed in this CPG.8 Viscoelastic testing should not be used to withhold TXA during initial resuscitation of bleeding trauma patients.9

Prolonged CPR > 20-30 min is generally futile in children who have cardiac arrest with trauma related injuries. Children with traumatic injuries with in-hospital cardiac arrest have a very high mortality after 20-30 min of cardiac arrest.10

References for Pediatric Considerations:

1. Neff LP, Cannon JW, Morrison JJ, et al. Clearly defining pediatric massive transfusion: cutting through the fog and friction with combat data. J Trauma Acute Care Surg, 2015. 78(1): p. 22-8; discussion 28-9.
2. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg, 2014. 77(6): p. 852-8; discussion 858.
3. Tzortzopoulou A, Cepeda MS, Shchumann R, et al. Antifibrinolytic agents for reducing blood loss in scoliosis surgery in children. Cochrane Database Syst Rev, 2008(3): p. CD006883.
4. Schouten ES, van de Pol AC, Schouten AN, et al. The effect of aprotinin, tranexamic acid, and aminocaproic acid on blood loss and use of blood products in major pediatric surgery: a meta-analysis. Pediatr Crit Care Med, 2009. 10(2): p. 182-90.
5. Basta MN, Stricker PA Taylor JA. A systematic review of the use of antifibrinolytic agents in pediatric surgery and implications for craniofacial use. Pediatr Surg Int, 2012. 28(11): p. 1059-69.
6. Grassin-Delyle S, Couturier R, Abe E, et al. A practical tranexamic acid dosing scheme based on population pharmacokinetics in children undergoing cardiac surgery. Anesthesiology, 2013. 118(4): p. 853-62.
7. Health, R.C.o.P.a.C. Major trauma and the use of tranexamic acid in children: Evidence statement. 2012 [cited 2016 July 14]; https://www.tarn.ac.uk/content/downloads/3100/121112_TXA%20evidence%20statement_final%20v2.pdf Accessed Jul 2019.
8. Nylund CM, Borgman MA, Holcom JB, et al. Thromboelastography to direct the administration of recombinant activated factor VII in a child with traumatic injury requiring massive transfusion. Pediatr Crit Care Med, 2009. 10(2): p. e22-6.
9. Inaba K, Rizoli S, Veigas PV, et al. 2014 Consensus conference on viscoelastic test-based transfusion guidelines for early trauma resuscitation: Report of the panel. J Trauma Acute Care Surg, 2015. 78(6): p. 1220-9.
10. Matos RI, Watson RS, Nadkarni VM, et al. Duration of cardiopulmonary resuscitation and illness category impact survival and neurologic outcomes for in-hospital pediatric cardiac arrests. Circulation, 2013. 127(4): p. 442-51.