Hemorrhagic shock in the pediatric trauma patient is an uncommon but fundamental problem for the treating clinician. Current management of hemorrhagic shock involves initial resuscitation with crystalloid fluids followed by infusion of blood components as necessary. In management of the adult trauma patient, many institutions have implemented massive transfusion protocols to guide transfusion in situations requiring or anticipating the use of greater than 10 U of packed red blood cells. In the pediatric population, guidelines for massive transfusion are vague or nonexistent. Adult trauma transfusion protocols can be applied to children until a pediatric protocol is validated. Here, we attempt to identify certain principles of transfusion therapy specific to pediatric trauma and outline a sample pediatric massive transfusion protocol that may be used to guide resuscitation. Also, adjuncts to transfusion, such as colloid fluids, other plasma expanders or hemoglobin substitutes, and recombinant activated factor VII, are discussed.
"Laboratory results may not be immediately available and coagulopathic states can change rapidly. Furthermore, most centres do not commonly encounter paediatric trauma patients who require massive transfusion and so there is a great amount of uncertainty regarding transfusion management . The purpose of this study is to describe our experience with massive transfusion in paediatric trauma patients with severe injuries in the absence of a massive transfusion protocol. "
[Show abstract][Hide abstract] ABSTRACT: Objectives
The purpose of this study was to quantify the incidence, patient profile, and outcomes associated with massive transfusion in paediatric trauma patients prior to establishing a massive transfusion protocol.
We performed a retrospective review of paediatric trauma patients treated at London Heath Sciences Centre between January 1, 2006 and December 31, 2011. Inclusion criteria were Injury Severity Score (ISS) greater than 12 and age less than 18 years.
435 patients met the inclusion criteria. 356 (82%) did not receive packed red blood cells in the first 24 hours, 66 (15%) received a non-massive transfusion (<40 mL/kg), and 13 (3%) received a massive transfusion (>40 mL/kg). Coagulopathy of any kind was more common in massive transfusion (11/13; 85%) than non-massive (32/66; 49%) (p = 0.037). Hyperkalemia (18% versus 23%; p = 0.98) and hypocalcemia (41% versus 46%; p = 1.00) were similar in both groups. Of the 13 massively transfused patients, 9 had multisystem injuries due to a motor vehicle collision, 3 had non-accidental head injuries requiring surgical evacuation, and 1 had multiple stab wounds. In the absence of a massive transfusion protocol, only 8 of the 13 patients received both fresh frozen plasma and platelets in the first 24 hours. Massive transfusion occurred in patients from across the age spectrum and was associated with severe injuries (mean ISS = 33), a higher incidence of severe head injuries (92%), longer hospital stay (mean = 36 days), and increased mortality (38%).
This study is the first to describe the incidence, complications, and outcomes associated with massive transfusion in paediatric trauma patients prior to a massive transfusion protocol. Massive transfusion occurred in 3% of patients and was associated with coagulopathy and poor outcomes. Protocols are needed to ensure that resuscitation occurs in a coordinated fashion and that patients are given appropriate amounts of fresh frozen plasma, platelets, and cryoprecipitate.
[Show abstract][Hide abstract] ABSTRACT: Across the United States, injuries from trauma are the leading causes of mortality and morbidity in children aged 19 years and younger. Over the past 2 decades, the “focused assessment with sonography for trauma” (FAST) examination has become a core application of emergency department ultrasound. In the last decade, the FAST examination has been “extended” to include evaluation of thoracic and extremity trauma. Use of contrast-enhanced ultrasound in pediatric abdominal trauma has been investigated in Europe with promising results that may further extend the capabilities of FAST. This article will review the evidence base for the FAST and extended FAST examinations as applied to pediatric trauma patients.
Clinical Pediatric Emergency Medicine 03/2011; 12(1):2. DOI:10.1016/j.cpem.2010.12.007
[Show abstract][Hide abstract] ABSTRACT: To determine the pattern, prevalence and potential complications of fresh frozen plasma (FFP) use in US pediatric hospitals from 2002-2009.
Retrospective cohort study using the Pediatric Health Information System (PHIS) administrative database, which was queried for FFP admissions using diagnostic, procedural, and billing codes. Demographic data, daily use, and procedural codes were used to describe the patient population and pattern of FFP use.
Of 3 252 149 PHIS-recorded admissions, 2.85% had codes consistent with FFP use. This percentage did not change over the course of the study (P=.10). FFP was most commonly administered to children <1 year of age (54%), critically ill children (70%), and those with heart disease (34%). Fifteen percent of FFP-related admissions involved a thrombotic event. The overall mortality rate was 17% and it decreased during the study (P<.001). There was noteworthy variation in the proportion of FFP admissions among participating institutions.
FFP is commonly used in children admitted to PHIS hospitals. Despite recent expert recommendations highlighting the lack of efficacy in many clinical scenarios, the rate of FFP use does not appear to be changing. Randomized, controlled studies are needed to determine appropriate indications for FFP use and evaluate for potential complications.
The Journal of pediatrics 09/2011; 160(2):210-215.e1. DOI:10.1016/j.jpeds.2011.08.013 · 3.79 Impact Factor
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