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MOP 300304

REVIEW

CURRENT
OPINION Damage control resuscitation in pediatric trauma
Meghan Gilley and Suzanne Beno

Purpose of review
Damage control resuscitation is an overall management strategy used in trauma patients to rapidly restore
physiologic stability, while mitigating hypothermia, coagulopathy and acidosis. We review the evidence
and current practice of damage control resuscitation in pediatric trauma patients with a specific focus on
fluid management.
Recent findings
There have been a number of studies over the last several years examining crystalloid fluid resuscitation,
balanced blood product transfusion practice and hemostatic agents in pediatric trauma. Excessive fluid
resuscitation has been linked to increased number of ICU days, ventilator days and mortality. Balanced
massive transfusion (1 : 1 : 1 product ratio) has not yet been demonstrated to have the same mortality
benefits in pediatric trauma patients as in adults. Similarly, tranexamic acid (TXA) has strong evidence to
support its use in adult trauma and some evidence in pediatric trauma.
Summary
Attention to establishing rapid vascular access and correcting hypothermia and acidosis is essential. A
judicious approach to crystalloid resuscitation in the bleeding pediatric trauma patient with early use of
blood products in keeping with an organized approach to massive hemorrhage is recommended. The ideal
crystalloid volumes and/or blood product ratios in pediatric trauma patients have yet to be determined.
Keywords
damage control resuscitation, massive transfusion protocol, pediatric trauma

INTRODUCTION considerations in the application of these strategies,

Trauma is the leading cause of morbidity and mor-
tality in children [1,2]. Blunt craniocervical trauma
is the most common cause of death in pediatric
patients; however, hemorrhage remains a leading
cause of preventable death. Damage control resus-
citation (DCR) is a management strategy widely
used in adult trauma resuscitation to attempt to
avoid the lethal triad of hypothermia, acidosis
&
and coagulopathy [3,4 ,5,6]. This strategy has
evolved over the past decade, but dates back to
World War II when whole-blood transfusion was
recommended based on the concept that both shock
and coagulopathy needed to be addressed for opti-
mal patient outcomes [7]. DCR today consists of
immediate hemorrhage control, limited use of crys-
talloid fluids, early use of warmed blood products,
balanced massive transfusion protocols (MTPs), per-
missive hypotension, use of hemostatic agents and
&
damage control surgery [4 ]. Evidence for these
strategies in the pediatric population is wanting,
and much of it derived from adult literature. Using
a case-based approach, we will review evidence for
DCR in pediatric trauma focusing on fluid manage-
ment and hemostasis. We will also discuss patient
as the adolescent patient has different anatomy,
physiology and mechanisms of trauma than the
young child.
CASE 1
A 5-year-old girl was struck by a car traveling at
65 km/h and thrown 10 ft away. Upon paramedic
arrival, the child had a Glasgow Coma Scale (GCS) of
14, heart rate (HR) of 150 and a blood pressure (BP)
of 85/60. She arrives to the emergency department
(ED) immobilized with a cervical spine collar
on a backboard with one intravenous line. You
note bruising on her abdomen and suspect intra-
abdominal injury as well as a pelvic fracture given
Division of Emergency Medicine, Hospital for Sick Children, University of
Toronto, Toronto, Ontario, Canada
Correspondence to Meghan Gilley, MD, Division of Emergency Medicine,
Hospital for Sick Children, University of Toronto, 525 University Ave,
Toronto, ON, Canada M5G1X8. Tel: +1 604 218-8614;
e-mail: Meghan.gilley@sickkids.ca
Curr Opin Pediatr 2018, 30:000–000
DOI:10.1097/MOP.0000000000000617

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MOP 300304
Emergency and critical care medicine
KEY POINTS
 Hemorrhage control and early vascular access
(intravenous or intraosseous) are essential initial
resuscitation strategies in the bleeding child.
 Judicious use of warmed crystalloid resuscitation
(10–40 ml/kg) in the pediatric trauma patient with
early initiation of blood product is appropriate.
 Attention to avoiding hypothermia and correcting
acidosis through appropriate volume expansion in the
injured bleeding child are paramount. Active warming
efforts include ambient temperature control, external
warmers and administration of warmed
intravenous fluids.
 Massive transfusion protocols should exist at major
pediatric centers; however, the ideal ratio of product
components for massive transfusion is not yet clear.
Currently, a balanced approach of 1 : 1 : 1 is utilized in
adult trauma patients.
 TXA requires further research before becoming
standard of care in pediatric trauma. It is however
reasonable to consider TXA in pediatric trauma patients
with active bleeding requiring transfusion, and in
adolescents as per adult protocols.
crepitus on examination. You are asked what you
would like in the way of further intravenous access
and fluids.
ACCESS
Intravenous access is the paramount first step in
initiating fluid resuscitation in trauma patients.
Pediatric patients can pose increased difficulty with
this task due to smaller vascular structures and
therefore limited cannulation options. Ideally an
18-gauge or larger catheter would be placed to facil-
itate use of a rapid infusion device, which can
deliver crystalloid fluids at rates up to 600 ml/min,
while simultaneously warming them [8]. Rapid
infusers are not compatible with smaller gauge cath-
eters, and one may instead use a pressure bag or
multiple handheld syringes to provide rapid fluid
resuscitation; however, neither of these methods
takes into account fluid warming. Warm fluids are
a necessity for trauma patients as cold or room
temperature fluids can worsen hypothermia and
contribute to coagulopathy. Fluids can be warmed
by placing them under forced air warmers or with a
Hotline Fluid Warmer (Smiths Medical, Dublin,
&
Ohio) [9 ]. If access is unobtainable after two
attempts (90 s or less), or the patient is in extremis,
then an intraosseous line should be placed without
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delay. Venous cutdowns and central access are rarely
used now for initial vascular access given the high
success rates of intraosseous placement, but are a
&
consideration if skilled personnel available [9 ].
CRYSTALLOID FLUID
The ideal amount of fluid in pediatric trauma resus-
citation is as of yet unclear. Adult trauma literature
supports limited use of crystalloid fluid and early
packed red blood cell (PRBC) transfusion, as evi-
dence suggests excess fluid resuscitation leads to
hemodilution of clotting factors with worsening
coagulopathy and acidosis, and can result in tissue
injury related to tissue edema [3,5]. Advanced
Trauma Life Support (ATLS) Student Manual. 9th
ed. Chicago, Illionois: American College of Sur-
geons; guidelines thus now suggest 1 instead of 2 l
of crystalloid for adult trauma [10]. Conversely, this
edition still recommends three boluses of 20 ml/kg
crystalloid prior to PRBC transfusion in pediatric
trauma. Similarly, 2010 pediatric advanced life sup-
port (PALS) guidelines support 60 ml/kg of crystal-
loid for hypovolemic shock, and whereas the 2015
PALS update acknowledged risk of aggressive fluid
resuscitation in certain populations, they did not
specifically address hemorrhagic shock [11]. The
Advanced Pediatric Life Support 2015 Update
(United Kingdom) has incorporated this practice
change and recommend immediate blood or
10 ml/kg aliquots of crystalloid prior to transfusion
&
in pediatric trauma [12 ]. Upcoming ATLS (10th
edition) guidelines may potentially address this
issue further.
Little evidence exists in pediatric trauma that
can direct these guideline changes. A 2015 study
done by Edwards et al. utilizing the Department of
Defense Trauma Registry examined children youn-
ger than 14 years requiring transfusion. Increased
crystalloid administration was associated with
increased intensive care and ventilator days, and
hospital stay when adjusted for age and Injury
Severity Score (ISS). Patients receiving more than
150 ml/kg in their first 24 h had a significantly
higher mortality rate (18 versus 10%, P ¼ 0.011)
when adjusted for ISS. Mortality was also increased
with fluid resuscitation less than 50 ml/kg in 24 h,
which the authors attributed to both early death and
inadequate resuscitation [13]. Acker et al. [14] simi-
larly found crystalloid resuscitation in excess of
60 ml/kg/24 h was associated with increased length
of stay and need for mechanical ventilation, but
increased rates of other complications were not
observed, thus concluding injured children appear
relatively resistant to some of the adverse effects of
early high-volume fluid resuscitation.
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Damage control resuscitation in pediatric trauma Gilley and Beno
Research delineating crystalloid volumes in chil-
dren is very much needed, as the approach can and
should vary based upon age and sustained injuries.
At this time, judicious crystalloid resuscitation
(10–40 ml/kg) in the injured and bleeding child
is appropriate for patients in compensated shock,
recognizing early transition to blood products is
necessary should their condition not improve. Chil-
dren in decompensated hemorrhagic shock need
blood immediately or as soon as logistically possible.
CASE 2
A 14-year-old boy was shot twice in the abdomen.
He arrives to your ED with a GCS of 14, HR of
120 and a BP of 85/60. His abdominal wounds are
actively bleeding.
HEMORRHAGE CONTROL
Hemorrhage control through surgical or nonsurgi-
cal means is a fundamental component of DCR.
Pelvic binders, direct pressure and tourniquet use
when necessary are essential prehospital interven-
tions that save lives. Modern tourniquet application
is estimated to have saved between 1000 and 2000
lives during the Iraq and Afghanistan wars [15–17].
Prehospital hemorrhage control has been so success-
ful that the Department of Homeland Security and
the American College of Surgeons launched ‘STOP
the Bleed’ in 2015 in response to the Sandy Hook
mass shooting [17,18]. This campaign is designed to
train and empower bystanders to help in a bleeding
emergency with application of direct pressure and
tourniquet use.
MASSIVE TRANSFUSION
Massive transfusion in pediatrics had not been
clearly defined prior to a 2015 study by Neff et al.,
in which massive transfusion was defined in a pedi-
atric combat trauma population by retrospectively
analyzing outcomes of over 3600 patients requiring
transfusion. Sensitivity and specificity analysis sug-
gested a massive transfusion definition of 40 ml/kg
(roughly half the circulating volume of a child) of
any blood product in the first 24 h as optimal for
differentiating pediatric patients at risk for both
early and late mortality [19]. This definition, albeit
derived in a combat population, has now been
incorporated into many pediatric MTPs across North
America.
MTPs are an element of hemostatic resuscitation
and are designed to correct hemorrhagic shock with
a balanced transfusion ratio of plasma, platelets and
PRBCs mimicking whole blood. In adult trauma, the
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goal is a 1 : 1 : 1 ratio to minimize clotting factor
hemodilution and coagulopathy; literature has
shown improved patient outcomes with early initi-
&
ation of balanced MTPs in trauma patients [5,9 ,20–
24]. The PROMMT and PROPPR trials are both large
multicenter prospective studies addressing this
issue; both support high plasma-to-PRBC transfu-
sion ratios in adult trauma patients given an associ-
ated mortality reduction from hemorrhage with
increased hemostasis [23,24]. The PROPPR trial
was a randomized control trial that looked specifi-
cally at transfusion ratios and found that adult
patients receiving 1 : 1 : 2 (plasma : platelets : PRBCs)
transfusion had no significant difference in mortal-
ity at 24 h or 30 days compared with those receiving
1 : 1 : 1, with the latter group achieving better hemo-
stasis and less death by exsanguination at 24 h [24].
Children appear to be at equal or higher risk for
coagulopathy with reported rates ranging from 10 to
77% [25]. Trauma-induced coagulopathy (TIC) is
thought to be driven by initial tissue injury and
shock, and worsened by hypothermia, acidosis
and hemodilution. TIC is also related to traumatic
brain injury (TBI), a common condition in children,
with ongoing research working to further elucidate
this phenomenon [25–27].
Thus, despite maturational differences in their
coagulation systems, it falls to reason that balanced
resuscitation in pediatric patients would have a
similar benefit as in adults, but this has not been
fully demonstrated in the literature to date
& &&
[13,28,29 ,30 ]. Case reports of children having
excellent outcomes without coagulopathy after
receiving balanced MTPs exist, but several studies
in pediatric trauma have not found the same benefit
of 1 : 1 : 1 transfusion to that seen in adult trauma
literature [31]. Nosanov et al. performed a retrospec-
tive review of 6675 pediatric trauma patients in
which 105 were massively transfused (greater than
50% of total blood volume in 24 h). They did not
find that plasma to platelet to PRBC ratios were
significantly associated with mortality; however,
limitations included small sample size, retrospective
nature, heterogenous ratios and exclusion of
patients dying within 24 h, making it susceptible
to survivorship bias [28]. Edwards et al. [13] actually
suggested an increase in mortality with aggressive
plasma transfusions; patients transfused with a ratio
equal to or greater than 0.8 Fresh Frozen Plasma
(FFP) to 1.0 PRBCs had significantly increased mor-
tality even when adjusted for age, ISS, mechanism
and volume of crystalloid. A retrospective review by
Cannon et al. compared pediatric patients receiving
massive transfusion with plasma : PRBC transfusion
ratios defined as ‘high’ (>1 : 2) versus ‘low’ (<1 : 2).
The ‘high’ group received less PRBCs but more FFP
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and total blood product volume, and had a longer
&&
length of stay [30 ]. Finally, Livingston et al. [32] in
a retrospective review of 435 patients in Canada
found that massive transfusion was utilized in 3%
of their patients and was associated with coagulop-
athy and poor outcomes; of note, without an estab-
lished massive hemorrhage protocol, only eight of
13 patients received plasma and platelets in the
first 24 h.
In summary, MTPs expedite access to PRBCs and
other blood products, and have shown clear mortal-
ity benefit in adults [3,23,24]. Although this evi-
dence for mortality reduction is not yet present in
pediatric trauma, it is strongly recommended that
pediatric institutions have MTPs available to orga-
&
nize and expedite product delivery [29 ,33,34]. In
addition, although it makes physiologic sense to
take a ‘balanced’ approach to the resuscitation of
a child in traumatic hemorrhagic shock, evidence
does not currently suggest that the 1 : 1 : 1 ratio is
ideal. Further research is necessary to clarify blood
product ratios in pediatric trauma.
TRANEXAMIC ACID
In adult trauma, tranexamic acid (TXA) is now a
cornerstone of hemostatic resuscitation with strong
supporting evidence in mortality reduction if used
&
early [35,36 ]. TXA is an antifibrinolytic agent that
reversibly binds to plasminogen, preventing the
degradation of fibrinogen and promoting clot sta-
bility. TXA in trauma is estimated to save one in 67
lives [35]. Evidence regarding the use of TXA in TBI
is pending the results of the CRASH 3 trial and other
ongoing studies [37].
Data in pediatric trauma patients is more lim-
ited, with the majority of pediatric literature doc-
umenting the use and benefit of TXA in spinal,
craniofacial and cardiac surgeries [38–41]. Nishijima
&
et al. [42 ] reviewed TXA use across US Childrens’
Hospitals from 2009 to 2013 and found 0.31% use
in trauma. The PED-TRAX study retrospectively
reviewed pediatric patients injured in Afghanistan
from 2008 to 2012, in which 66 (9%) of 766 children
received TXA. When adjusted for demographics,
injury type, severity, vitals and laboratory parame-
ters, TXA was independently associated with
decreased mortality without significant increase
in thromboembolic events. In addition, patients
receiving large volume transfusion with TXA had
improved neurological outcomes [41]. Although
data to support widespread use in pediatric trauma
remains limited, widespread use in other clinical
situations and preliminary evidence in trauma is
suggestive of benefit with minimal harm or cost.
As of 2017, TXA requires further investigation in
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pediatric trauma before widely implementing in all
age groups and all clinical situations. Further
research is absolutely necessary in young injured
children; it is however appropriate to treat adoles-
cent patients as adults with respect to their anat-
omy, physiology and response to blood loss and
resuscitation. It is reasonable to consider TXA in
pediatric trauma, and to administer TXA within the
first 3 h of presentation if actively bleeding and
requiring blood products [43].
PERMISSIVE HYPOTENSION
Permissive hypotension is a resuscitation strategy
based upon observations that trauma patients
with uncontrolled hemorrhagic shock worsen with
intravenous fluid resuscitation, likely related to
coagulopathy and hemodilution, but also to desta-
bilization of the clot with increased hydrostatic
pressure [21]. Permissive hypotension as a resuscita-
tive strategy balances an acceptable amount of
hypotension with end-organ ischemia and hypoxia
until surgical or interventional control of the
bleeding can be established, essentially tolerating
a palpable pulse and mentation as opposed to resus-
citating to a normal BP. Permissive hypotension has
most benefit in specific scenarios, such as hemor-
rhage from an arterial source. It is controversial and
not recommended in patients with concomitant
&
head injuries [44 ].
There is no evidence supporting the use of per-
missive hypotension in pediatrics. In addition, there
is significant concern for use of this strategy based
on the understood physiologic response pediatric
patients have to hypovolemia; children’s ability to
increase HR and utilize peripheral vasoconstriction
to maintain BP means that hypotension is a late sign
of shock and represents a critical and uncompen-
&
sated state [4 ,21]. Permissive hypotension for
young children is therefore not currently recom-
mended due to lack of evidence, physiologic con-
siderations and high rates of concomitant TBI.
Certain clinical scenarios may challenge this view
point: specifically the adolescent population is more
similar in physiology to adults, and therefore,
management strategies may include permissive
hypotension. There can be nuanced approaches to
utilizing this DCR strategy in pediatric trauma.
ROTATIONAL THROMBOELASTOMETRY/
THROMBOELASTOGRAPHY
Viscoelastic hemostatic assays (VHA) such as rota-
tional thromboelastometry (ROTEM) and throm-
boelastography (TEG) are functional assays that
provide rapid information regarding clot formation,
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Damage control resuscitation in pediatric trauma Gilley and Beno
propogation and stability; this information helps
determine the coagulopathic state of the patient
to better guide transfusion of blood products in
&
hemostatic resuscitation [45 ,46]. A systematic
review of VHA use in adult trauma patients suggests
ROTEM and TEG are superior to routine coagulation
tests in detecting early trauma coagulopathy, with
major abnormalities in VHA testing predicting the
need for massive transfusion and even death [47]. A
retrospective review of rapid Thrombelastography
used in 86 pediatric trauma patients showed it pro-
vided useful and actionable information for trans-
fusion and life-saving interventions, and was
predictive of mortality [48]. There is further evi-
dence in children that International Normalized
Ratio (INR) values are prognostic of mortality, but
are not diagnostic of clinical coagulopathy and
& &
should not be used as a clinical target [45 ,49,50 ].
CONCLUSION
DCR is an overall approach consisting of life-saving
management strategies that define care in adult
trauma. Many of these principles can and should
be applied to pediatric trauma management. How-
ever, further research in this population is needed to
better elucidate specific care goals and outcomes,
such as the ideal amount of crystalloid fluid admin-
istration, MTP ratios of blood products and TXA use.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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