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: