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PEDIATRIC READINESS

PROGRAM EDUCATION

SESSION

This activity has been planned and implemented in

accordance with the accreditation requirements and

policies of the Accreditation Council for Continuing

Medical Education (ACCME) through the joint

providership of Legacy Health and Oregon Emergency

Medical Services for Children.

Legacy Health designates this live activity for a

maximum of 1.0 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate

with the extent of their participation in the activity.

PEDIATRIC TRAUMA

UPDATE

Nicholas Hamilton, MD, FAAP, FACS

Trauma Medical Director, Doernbecher Children’s Hospital

Associate Professor Pediatric Surgery, OHSU

May 19, 2022

CME DISCLOSURE

None of the planners and faculty for this educational

activity have relevant financial relationship(s) to

disclose with ineligible companies whose primary

business is producing, marketing, selling, reselling,

or distributing healthcare products used by or on

patients.

Why is appropriate trauma care important in

children?

• Leading cause of death in children in America

• 11,000 <18 annually

• Over 17 million ED visits/year

• 90% blunt trauma

OBJECTIVES

• Discuss changes in initial fluid resuscitation in

traumatically injured children.

• Review massive transfusion protocols and the use

of whole blood in pediatric patients.

• Describe changes in the management for

pediatric solid organ injuries.

Fluids, Transfusion

and Coagulopathy

Fluid resuscitation

• Fluid resuscitation/volume repletion is cornerstone of

initial trauma resuscitation

• Must recognize issue is intravascular volume loss

• Fluid >>> pressors

Shock

• Initial fluid resuscitation recommendations

• 20ml/kg crystalloid bolus x 2

• Hesitancy to transfuse children

• Processing of blood, antibody concerns, etc…

Transfusion Medicine Reviews 30 (2016) 235–241

Shock Index- Pediatric Adjusted (SIPA)

• Children become hypotensive later into shock and most

common abnormal vital sign is heart rate

• Calculation of SIPA can help resuscitation

• Calculated by maximum heart rate/minimum systolic blood

pressure

• Elevated at >1.22 for 4-6.9 y/o, >1.0 for 7-12.9y/o and >0.9 for 13-

16.9 y/o

• Predicted need for OR, intubation and transfusion

Journal of Pediatric Surgery 52 (2017) 340–344

Crystalloid isn’t

all it’s cracked up

to be (duh, duh,

dum)…

When stratifying amount

of crystalloid

resuscitation received,

found that patients

receiving

>60ml/kg in first 24

hours had significantly

higher LOS, days NPO

>60ml/kg/day over 48

hours, higher ICU LOS,

hospital LOS, vent days,

days NPO

Journal of Pediatric Surgery 53 (2018) 2202–2208

ICU LOS

Hospital LOS

Vent Days

NPO Days

Fluid resuscitation first 24 hours

Transfuse earlier, but when?

• Targeted transfusion

• Massive transfusion

Targeted transfusion

• Using ROTEM / TEG (ROtational ThromboElastoMetry

and ThromboElastoGraphy)

• Viscoelastic tests of clotting function

• Point of care that take around 10-20 minutes for results

• <1ml blood put in a little cup and a pin put in it, and it rotates

• See how clotting works based on how the rotation is impeded (by

clot formation)

• **Tests fibrinolysis

• Can differentiate between thrombocytopenia and low fibrinogen causes

of coagulopathy

Derangedphysiology.com

https://www.emra.org/emresident/article/teg-and-rotem/

Can predict transfusion and disability

• Study done here in Portland between

OHSU/Doernbecher and Emanuel/Randall

• 90 patients

• ROTEM thresholds:

• Plasma: EXTEM CT > 84.5 seconds

• Fibrinogen: EXTEM A10 < 43.5 mm

• Platelets: EXTEM MCF < 64.5 mm

J Trauma Acute Care Surg.2020;88: 134–140

ROTEM results

What if they are *really* bleeding?

• Massive transfusion protocol (MTP)

• Considered in adult when > 10u pRBC over 24 hours, but no such

definition exists in children

• More physiologic

• Studies

• 1:1:1 (vs 1:1:2)

• Helpful because comes with all components and they are all just

given

• *Do not pick and choose what you want from the box*

• 8 minutes to get PRBC

• 34 minutes to get FFP (plasma)

• 42 minutes for platelets

• 28-day mortality 36.1%

2.Critical Care Medicine. 2021;49:1943-54

Alberta Children’s Hospital’s MTP

Components are Key

• The role of plasma

• PTQIP center study from

2014-2016

• Of patients who received

>1:1 FFP:pRBC, there was

a 51% lower risk of death

• Of patients who received

1:1> FFP:pRBC >1:2,

there was a 40% lower risk

of death

• Platelet:pRBC ratio not

associated with mortality

change

Crit Care Med 2019; 47:975–983

1:1 seems to be the best in kids

• ATOMAC study:

• Patients >20 ml/kg or

MTP included

• Increased mortality

(OR 3.08) per unit

increase over 1:1 ratio

pRBC : FFP

Journal of Pediatric Surgery 54 (2019) 345–349

Components are Key

• The role of cryoprecipitate

• PTQIP center study from 2014-2017

• Of patients who underwent massive transfusion within the first 4

hours of ED arrival:

• Patients receiving cryoprecipitate had lower 24 hour mortality compared

to those who did not (6.9% less)

• Also associated with lower 7-day mortality in children with penetrating

trauma or those transfused at least 100ml/kg total blood products

JAMA Surg. 2021;156(5):453-460

Let’s Give All the Components at Once!

• Whole blood is making a comeback

• Demonstrated to be safe in adults, but…

J Trauma AcuteCare Surg. 2020;89: 238–245.

That said…

Propensity score matching of 28:28 patients

• Whole blood faster resolution of base deficit (2 vs 6 hours)

• Improved post-transfusion INR

• Lower plasma volumes and platelet volumes

• No difference in LOS, ICU LOS, ventilator or survival

(Ann Surg 2020;272:590–594)

Others Agree

• 2017 TQIP database

• Propensity score 1:2 ratio

• 135 WB : 270 components

• Decreased total products transfused with no difference in

mortality, LOS, major complications, but did have fewer

ventilation days with WB

J Trauma Acute Care Surg. 2021;91: 573–578.

What about TXA?

• Tranexamic acid (TXA) has been shown to decrease

mortality in adult trauma

• Studied initially in combat (Iraq and Afghanistan)

• When patients needed >40ml/kg blood products, use of

TXA led to in hospital death decrease from 18.3% to 8.5%

• That said, only 35% of pediatric trauma centers use it

• Dosing 15mg/kg bolus with 2mg/kg/hr x 8 hours

JTACS. 2020;89:S242-5. J Trauma Nurs. 2021;28:21-5.

Take Home Points

Following adult shift to earlier transfusion

Whole blood is safe in children, but we are

still learning

There is a role for advanced coagulation

monitoring

Blunt Solid Organ

Injuries in

Children

Abdominal Trauma

• ~10% of patients with blunt trauma will have intra-

abdominal injury

• 40% less fatal than thoracic injuries

• Children smaller, so kinetic energy more impactful

• Ribs less calcified→more force gets into chest and upper

abdomen

• Abdominal walls thinner and muscles weaker

Emerg Med Clin N Am 36 (2018) 237–257

Screening patients

• FAST exam

• Combined with AST/ALT

>100 is effective screen

• Urinalysis

• >8 red cells associated

with splenic/renal

lacerations

•

J Urol. 1996;156:2014-8.

• Also check Amylase

&/or Lipase

https://pubs.rsna.org/doi/full/10.1148/radiol.2017160107

J Surg Res. 2009;157:103-7

CT Scan

The long ago…

J Pediatr Surg 39:487-490.

Hemodynamically Normal*:

Oregon Pediatric Solid Organ Injury Management Protocol

Hemodynamically Abnormal*:

Defined as tachycardia/hypotension for age

after initial volume resuscitation

*Contact Pediatric Surgery as soon as

possible

-Admit to PICU

-NPO until VS normal and Hct stable x 12 hours

-Bathroom privileges (vs bedrest?) x 12 hours

-VS per ICU routine (at least q 1hr x 4 hrs, then

q 4hr if stable

-Hct q 6 hr until stable x 2

Consider transfusion if Hct < 21

Consider:

-Angioembolization for signs of ongoing

bleeding

*Not indicated for contrast blush on CT

with stable VS*

-Operative exploration for unstable VS

despite pRBC transfusion.

-MTP activation

Continued instability

Discharge criteria:

-Tolerating diet

-Minimal abdominal pain

- Normal vital signs

6 weeks of no contact sports

Admit Hct > 35

-No activity restriction

-Regular diet

If stable after 12 hours of observation, evaluate for

discharge

Admit Hct < 35

-Bathroom privileges

-NPO

If stable after 12 hours of observation,

-recheck Hct

Hct stable (<3 point change)

-Regular diet

-Ambulate

Evaluate for discharge

after 6 hours

Hct unstable (>3 pt

change)

-Recheck Hct q6h until

stable

-Consider transfusion if

Hct < 21

-Consider transfer to

PICU if

VS unstable

-Admit to ward

-VS q2h x 2, then q4h

Admission Hct

Definitions:

Normal vital signs (VS): normal for age

after initial volume resuscitation

Hct: hematocrit

NPO: nothing by mouth

pRBC: packed red blood cell

MTP: massive transfusion protocol

VS normalize and

Hct stable x 12 hours

*If grade III-V renal laceration:

Obtain 10 minute delayed CT

Unique aspects of retroperitoneal organs

Kidney

• When grade > 3, should

get delayed images to

examine for urine leak

•

J Pediatr Urol. 2016;12:294e1-

• May be unnecessary, as

adult study showed

interventions increased

without symptoms in

patients reimaged

•

JTACS 2021;90:143-7.

Pancreas

• No one really knows what

to do with these

• Head- try to drain +/-

ERCP/stent

• Try to avoid operation

• Tail- ongoing study of

observation +/- stent vs distal

pancreatectomy

Role for post-injury imaging/follow up

• In renal trauma, complications (urinoma, sepsis,

hydronephrosis, persistent hypertension) occurs in grade

3-4 injuries.

• Concern for loss of renal function warrants follow up 3-4 months

• Ultrasound, renal scan

• For liver or spleen injury, routine imaging unwarranted

Pediatr Radiol. 1994;24:573-6

Journal of Pediatric Surgery 54 (2019) 340–344

Take Home Points

Most blunt solid organ injuries in children

can be managed non-operatively

Failure of non-operative management is

usually within the first 6 hours following

injury

Hemodynamics should guide treatment

more than imaging grade/severity

THANK YOU!

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