Paediatric trauma resuscitation an update

Authors: T H Tosounidis P V Giannoudis

Publish Date: 2015/12/22

Volume: 42, Issue: 3, Pages: 297-301

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Abstract

Paediatric trauma is the leading cause of mortality in children Paediatric trauma resuscitation is the first and foremost step towards a successful treatment and subsequent recovery Significant advances have taken place in the last years in relation to this field of trauma careIn this narrative review we attempt to summarise the recent development in the concepts of fluid resuscitation massive transfusion permissive resuscitation management of coagulopathy and use of tranexamic acid literature pertaining to implementation of transfusion protocols in the paediatric population and education related to the paediatric trauma resuscitationTrauma continues to be the leading cause of mortality in children and contemporary evidence suggests that in developed countries trauma is also the major cause of disability in the paediatric population 1 2 Paediatric trauma resuscitation constitutes the first of  the multiple steps that are needed to achieve full recovery of the traumatised child a feasible goal that should always be taken into consideration given the remarkable degree of recovery observed in polytrauma children The vast majority of literature pertaining to the acute trauma care is derived from studies in adults Nevertheless the paediatric trauma population represents a unique challenge due to differences in anatomy physiology and agespecific considerations In this narrative review of the literature we attempt to summarise the advances that have taken place over the last 5 years in paediatric trauma resuscitation with emphasis on fluid resuscitation massive transfusion permissive resuscitation management of coagulopathy and use of tranexamic acid and evidence pertaining to implementation of transfusion protocols in the paediatric population Considering the importance and inherent difficulties in education related to paediatric resuscitation we also present some of new evidences regarding the use of simulation in paediatric resuscitationFluid resuscitation necessitates a potent vascular access It has recently been highlighted that vascular access for adequate fluid resuscitation can be a challenge in the prehospital setting 3 4 A retrospective review 5 evaluating the emergency medical service interventions including endotracheal intubation intravenous access and fluid resuscitation demonstrated that the prehospital care of children was substantially deficient in comparison to the one provided to adults In particular compared to adults more children required venous access upon their arrival to the hospital The authors attributed the above finding to hypovolemia at presentation and observed increased number of adverse events related to unsuccessful attempts such as bruises and hematomasFluid resuscitation in the paediatric population should be physiologydriven and at the same time respect the different aspects of agerelated differences in this population Excessive fluid resuscitation might be harmful and uptodate there are no firm guidelines regarding the optimal resuscitation fluid volume in paediatric trauma In a retrospective review of the practice of a designated paediatric trauma centre in Canada AlSarif et al studied the practice of fluid resuscitation and the associated complications in nonhemorrhagic blunt trauma paediatric patients The authors concluded that the administered fluid volume was excessive and that 12  of the 139 patients that were included in the study developed “fluid resuscitation attributable complications” such as ascites and/or pleural effusions The authors concluded that overresuscitation is a common and potentially harmful phenomenon in nonhemorrhagic paediatric trauma In the same line Edwards et al in a recent retrospective review of Department of Defense Trauma Registry US military of 907 children 14 years old or younger concluded that crystalloidpredominant resuscitation had a negative effect on mortality hospital and intensive care length of stay and increased ventilator days The above effect was also evident even when adjusted for age and Injury Severity Score Interestingly balanced component resuscitation with FFP and RPBCs or whole blood did not yield better results as well The authors point out that further studies are needed to determine the effects of balanced resuscitation in the bleeding paediatric patients and suggest that future research should focus on delineation of appropriate physiologic triggers of resuscitation strategies based on the age of the patientMassive transfusion is a strategy to deal with the bleeding critically ill trauma patient by administering large volume of blood products in a short period of time It is a wellestablished practice in the adult population and over the last years it has been clearly proven beneficial for the adult trauma patient 6 7 Massive transfusion protocols for children are not yet fully developed 8 but this field has recently gained attention and massive transfusion protocols for the paediatric population have started emerging Nevertheless the vast majority of the existing studies are retrospective in nature and the level of evidence is lowDefining massive transfusion is of paramount importance In the adult population various definitions exist 6 Similarly several different definitions have been created for the paediatric trauma population with none being universally accepted 9 10 Recently Diab et al 8 suggested the following dynamic definition of massive transfusion in children and neonates “transfusion of 50  TBV in 3 h transfusion 100  TBV in 24 h or transfusion support to replace ongoing blood loss of 10  TBV per min” Moreover Neff et al 11 utilised data from the Department of Defense Trauma Registry US Military and retrospectively reviewed 1113 paediatric 18 years of age trauma combatinjured patients that were transfused during the resuscitation process The authors concluded that 40 ml/kg of all blood products administered at any time within the first day could identify the critically traumatised patients who are at increased risk for early and inhospital death Consequently the authors considered the above cut off point as critical in defining massive transfusion in paediatric population and suggested that since this definition is irrelevant to the injury mechanism and also takes into account contemporary transfusion practices it could be reliably used in future clinical research Livinston et al 12 reviewed the incidence patients’ characteristic and outcomes of massive transfusion in a paediatric trauma cohort of 435 patients The authors aimed to evaluate the outcomes of massive transfusion when it was used prior to the implementation of a specific protocol Massive transfusion took place in 3  of the patients and was correlated to poor outcome severe injuries higher incidence of head trauma and longer duration of hospital stay Coagulopathy occurred more frequently when massive transfusion was implemented The authors concluded that better coordination and attention to the correct amounts of frozen plasma cryoprecipitate and platelets is needed when this tactic is used

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