Skip to main content
SpringerLink
Log in

The Use of Blood in Pediatric Trauma Resuscitation

  • Pediatric Surgery (A. Fischer, Section Editor)
  • Published:
Current Surgery Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Death due to hemorrhage is the leading cause of preventable mortality in children. Although advances have been made in the treatment of injured adults, less is known about optimal resuscitation strategies for bleeding children. The following review summarizes recent studies and current resuscitation practices in children and identifies remaining knowledge gaps.

Recent Findings

Excessive crystalloid infusion has been found to contribute to dilutional anemia, coagulopathy, and acidosis. Recent studies recommend judicious use of crystalloid and prompt transition to blood product transfusion. Massive transfusion protocols can organize resuscitation strategies but require standardized criterion and uniform implementation. Balanced resuscitation practices may be beneficial, although the ideal ratios of plasma, platelets, and red blood cells remain unknown. Whole blood may additionally improve outcomes, reduce risk of transfusion-associated complications, and prevent trauma-induced coagulopathy. Antifibrinolytic agents may also improve survival.

Summary

Although pediatric resuscitation strategies have historically been based on principles established within the adult population, children’s  unique physiology requires focused investigation. Recent studies have shown improved outcomes with restrictive crystalloid use, balanced transfusions, whole blood, and antifibrinolytic agents. In order to further identify optimal resuscitation strategies, additional prospective observational studies and randomized controlled trials are needed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently have been highlighted as: • Of importance

  1. National Center for Injury Prevention and Control CfDaP. 10 Leading Causes of Death, United States. National Center for Health Statistics (NCHS). https://wisqars.cdc.gov/fatal-leading. Published 2020. Accessed.

  2. Klein J, Prabhakaran K, Latifi R, Rhee P. Firearms: the leading cause of years of potential life lost. Trauma Surg Acute Care Open. 2022;7(1):e000766.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Kauvar DS, Lefering R, Wade CE. Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma. 2006;60(6 Suppl):S3-11.

    PubMed  Google Scholar 

  4. ∙Gaines BA, Yazer MH, Triulzi DJ, et al. Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion. Ann Surg. 2021. First to show survival benefit at 72 hours and 28 days with LTOWB resuscitation versus conventional component therapy.

  5. Theodorou CM, Galganski LA, Jurkovich GJ, et al. Causes of early mortality in pediatric trauma patients. J Trauma Acute Care Surg. 2021;90(3):574–81.

    Article  PubMed  PubMed Central  Google Scholar 

  6. ∙Leonard JC, Josephson CD, Luther JF, et al. Life-threatening bleeding in children: a prospective observational study. Crit Care Med. 2021;49(11):1943–54. MATIC prospective observational study of children requiring massive transfusions from 24 children’s hospitals which noted that death from hemrrhage occurs rapidly in this population and comparing resuscitation and outcomes among operative, traumatic, and medical causes of life-threatening bleeding in children.

  7. ∙Spinella PC, Leonard JC, Marshall C, et al. Transfusion ratios and deficits in injured children with life-threatening bleeding. Pediatr Crit Care Med. 2022;23(4):235–44. Secondary analysis of the MATIC study which found that balanced resuscitaion of pRBC, plasma, and platelets improves early survival.

  8. Shroyer MC, Griffin RL, Mortellaro VE, Russell RT. Massive transfusion in pediatric trauma: analysis of the National Trauma Databank. J Surg Res. 2017;208:166–72.

    Article  PubMed  Google Scholar 

  9. ∙Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive transfusion in pediatric patients. Clin Lab Med. 2021;41(1):35–49. Reviews massive transfusions protocols in children and the variety of definitions and activation criteria used.

  10. Clebone A. Pediatric trauma transfusion and cognitive aids. Curr Opin Anaesthesiol. 2018;31(2):201–6.

    Article  PubMed  Google Scholar 

  11. Moore FA. The use of lactated ringer’s in shock resuscitation: the good, the bad and the ugly. J Trauma. 2011;70(5 Suppl):S15-16.

    PubMed  Google Scholar 

  12. Hahn RG. Adverse effects of crystalloid and colloid fluids. Anaesthesiol Intens Ther. 2017;49(4):303–8.

    Google Scholar 

  13. ∙Schauer SG, April MD, Becker TE, Cap AP, Borgman MA. High crystalloid volumes negate benefit of hemostatic resuscitation in pediatric wartime trauma casualties. J Trauma Acute Care Surg. 2020;89(2S Suppl 2):S185–91. Reviews Department of Defense Trauma Registry data and evaluates transfusion ratios and crystalloid resuscitation in children receiving massive transfusions.

  14. Wu F, Chipman A, Pati S, Miyasawa B, Corash L, Kozar RA. Resuscitative strategies to modulate the endotheliopathy of trauma: from cell to patient. Shock. 2020;53(5):575–84.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Robinson BRH, Cohen MJ, Holcomb JB, et al. Risk factors for the development of acute respiratory distress syndrome following hemorrhage. Shock. 2018;50(3):258–64.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Duke MD, Guidry C, Guice J, et al. Restrictive fluid resuscitation in combination with damage control resuscitation: time for adaptation. J Trauma Acute Care Surg. 2012;73(3):674–8.

    Article  CAS  PubMed  Google Scholar 

  17. Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle D. The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg. 2015;78(2):330–5.

    Article  PubMed  Google Scholar 

  18. ∙Polites SF, Moody S, Williams RF, et al. Timing and volume of crystalloid and blood products in pediatric trauma: an Eastern Association for the Surgery of Trauma multicenter prospective observational study. J Trauma Acute Care Surg. 2020;89(1):36–42. Multicenter prospective observational study from 24 truama centers evaluating pediatric trauma patients with elevated shock indexes which showed worse outcomes with higher volume crystalloid infusion.

  19. Zhu H, Chen B, Guo C. Aggressive crystalloid adversely affects outcomes in a pediatric trauma population. Eur J Trauma Emerg Surg. 2021;47(1):85–92.

    Article  PubMed  Google Scholar 

  20. Coons BE, Tam S, Rubsam J, Stylianos S, Duron V. High volume crystalloid resuscitation adversely affects pediatric trauma patients. J Pediatr Surg. 2018;53(11):2202–8.

    Article  PubMed  Google Scholar 

  21. ∙Polites SF, Nygaard RM, Reddy PN, et al. Multicenter study of crystalloid boluses and transfusion in pediatric trauma-When to go to blood? J Trauma Acute Care Surg. 2018;85(1):108–12. Reviews level 1 pediatric trauma activations at two level 1 trauma centers and supports early transition to blood transfusion.

  22. Borgman MA, Spinella PC, Perkins JG, et al. The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital. J Trauma. 2007;63(4):805–13.

    PubMed  Google Scholar 

  23. Holcomb JB, del Junco DJ, Fox EE, et al. The prospective, observational, multicenter, major trauma transfusion (PROMMTT) study: comparative effectiveness of a time-varying treatment with competing risks. JAMA Surg. 2013;148(2):127–36.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  25. Dressler AM, Finck CM, Carroll CL, Bonanni CC, Spinella PC. Use of a massive transfusion protocol with hemostatic resuscitation for severe intraoperative bleeding in a child. J Pediatr Surg. 2010;45(7):1530–3.

    Article  PubMed  Google Scholar 

  26. Livingston MH, Singh S, Merritt NH. Massive transfusion in paediatric and adolescent trauma patients: incidence, patient profile, and outcomes prior to a massive transfusion protocol. Injury. 2014;45(9):1301–6.

    Article  PubMed  Google Scholar 

  27. Diab YA, Wong EC, Luban NL. Massive transfusion in children and neonates. Br J Haematol. 2013;161(1):15–26.

    Article  PubMed  Google Scholar 

  28. Nunez TC, Voskresensky IV, Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66(2):346–52.

    PubMed  Google Scholar 

  29. Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric Trauma BIG Score: Predicting Mortality in Children After Military and Civilian Trauma. Pediatrics. 2011;127(4):E892–7.

    Article  PubMed  Google Scholar 

  30. Acker SN, Hall B, Hill L, Partrick DA, Bensard DD. Adult-based massive transfusion protocol activation criteria do not work in children. Eur J Pediatr Surg. 2017;27(1):32–5.

    PubMed  Google Scholar 

  31. Phillips R, Acker SN, Shahi N, et al. The ABC-D score improves the sensitivity in predicting need for massive transfusion in pediatric trauma patients. J Pediatr Surg. 2020;55(2):331–4.

    Article  PubMed  Google Scholar 

  32. Phillips R, Shahi N, Acker SN, et al. Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma. J Trauma Acute Care Surg. 2022;92(2):422–7.

    Article  CAS  PubMed  Google Scholar 

  33. Stevens J, Reppucci ML, Meier M, et al. Pre-hospital and emergency department shock index pediatric age-adjusted (SIPA) “cut points” to identify pediatric trauma patients at risk for massive transfusion and/or mortality. J Pediatr Surg. 2022;57(2):302–7.

    Article  PubMed  Google Scholar 

  34. Zhu CS, Braverman M, Goddard S, et al. Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion. J Trauma Acute Care Surg. 2021;91(4):579–83.

    Article  PubMed  Google Scholar 

  35. Hendrickson JE, Shaz BH, Pereira G, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52(6):1228–36.

    Article  CAS  PubMed  Google Scholar 

  36. Hwu RS, Spinella PC, Keller MS, Baker D, Wallendorf M, Leonard JC. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion. 2016;56(11):2712–9.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Chidester SJ, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012;73(5):1273–7.

    Article  PubMed  Google Scholar 

  38. ∙Horst J, Leonard JC, Vogel A, Jacobs R, Spinella PC. A survey of US and Canadian hospitals' paediatric massive transfusion protocol policies. Transfus Med. 2016;26(1):49–56. Surveys massive transfusion protocols at 46 hospitals and descbribes the range of activation criteria and availability of blood products and adjuncts.

  39. Evangelista ME, Gaffley M, Neff LP. Massive transfusion protocols for pediatric patients: current perspectives. J Blood Med. 2020;11:163–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Sperry JL, Ochoa JB, Gunn SR, et al. An FFP:PRBC transfusion ratio >/=1:1.5 is associated with a lower risk of mortality after massive transfusion. J Trauma. 2008;65(5):986–93.

    PubMed  Google Scholar 

  41. Cunningham ME, Rosenfeld EH, Zhu H, Naik-Mathuria BJ, Russell RT, Vogel AM. A high ratio of plasma: RBC improves survival in massively transfused injured children. J Surg Res. 2019;233:213–20.

    Article  PubMed  Google Scholar 

  42. Butler EK, Mills BM, Arbabi S, et al. Association of blood component ratios with 24-hour mortality in injured children receiving massive transfusion. Crit Care Med. 2019;47(7):975–83.

    Article  PubMed  PubMed Central  Google Scholar 

  43. ∙Noland DK, Apelt N, Greenwell C, et al. Massive transfusion in pediatric trauma: An ATOMAC perspective. J Pediatr Surg. 2019;54(2):345–9. Review of level 1 pediatric trauma activations at five ceners who requiried MTP activation of >20 ml/kg pRBCs and found that balanced proportions of pRBC to plasma improve survival.

  44. Hwu R, Keller MS, Spinella PC, Baker DTY, Leonard JC. Potential effects of high plasma to red blood cell ratio transfusion in pediatric trauma. Trauma. 2017;19(1):21–7.

    Article  Google Scholar 

  45. Nosanov L, Inaba K, Okoye O, et al. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013;206(5):655–60.

    Article  PubMed  Google Scholar 

  46. Holcomb JB, Zarzabal LA, Michalek JE, et al. Increased platelet:RBC ratios are associated with improved survival after massive transfusion. J Trauma. 2011;71(2 Suppl 3):S318-328.

    PubMed  Google Scholar 

  47. Anand T, Obaid O, Nelson A, et al. Whole blood hemostatic resuscitation in pediatric trauma: a nationwide propensity-matched analysis. J Trauma Acute Care Surg. 2021;91(4):573–8.

    Article  PubMed  Google Scholar 

  48. Leeper CM, Yazer MH, Triulzi DJ, Neal MD, Gaines BA. Whole blood is superior to component transfusion for injured children: a propensity matched analysis. Ann Surg. 2020;272(4):590–4.

    Article  PubMed  Google Scholar 

  49. Pidcoke HF, McFaul SJ, Ramasubramanian AK, et al. Primary hemostatic capacity of whole blood: a comprehensive analysis of pathogen reduction and refrigeration effects over time. Transfusion. 2013;53(Suppl 1):137S-149S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Jobes D, Wolfe Y, O’Neill D, et al. Toward a definition of “fresh” whole blood: an in vitro characterization of coagulation properties in refrigerated whole blood for transfusion. Transfusion. 2011;51(1):43–51.

    Article  CAS  PubMed  Google Scholar 

  51. Williams J, Merutka N, Meyer D, et al. Safety profile and impact of low-titer group O whole blood for emergency use in trauma. J Trauma Acute Care Surg. 2020;88(1):87–93.

    Article  PubMed  Google Scholar 

  52. Shea SM, Staudt AM, Thomas KA, et al. The use of low-titer group O whole blood is independently associated with improved survival compared to component therapy in adults with severe traumatic hemorrhage. Transfusion. 2020;60(Suppl 3):S2–9.

    CAS  PubMed  Google Scholar 

  53. ∙Leeper CM, Yazer MH, Cladis FP, Saladino R, Triulzi DJ, Gaines BA. Use of uncrossmatched cold-stored whole blood in injured children with hemorrhagic shock. JAMA Pediatr. 2018;172(5):491–2. First cohort of civilian pediatric trauma patients to receive whole blood during resuscitation, showing that whole blood transfusion up to 20 ml/kg were safe.

  54. Nadler R, Mozer-Glassberg Y, Gaines B, Glassberg E, Chen J. The Israel Defense Forces experience with freeze-dried plasma for the resuscitation of traumatized pediatric patients. J Trauma Acute Care Surg. 2019;87(6):1315–20.

    Article  PubMed  Google Scholar 

  55. ∙Morgan KM, Yazer MH, Triulzi DJ, Strotmeyer S, Gaines BA, Leeper CM. Safety profile of low-titer group O whole blood in pediatric patients with massive hemorrhage. Transfusion. 2021;61 Suppl 1:S8–S14. Review of pediatric patients receiving low titer group O whole blood (LTOWB) and compared outcomes between recipients who were group O versus non-group O, which found that use of LTOWB up to 40 ml/kg was safe.

  56. ∙Leeper CM, Yazer MH, Morgan KM, Triulzi DJ, Gaines BA. Adverse events after low titer group O whole blood versus component product transfusion in pediatric trauma patients: A propensity-matched cohort study. Transfusion. 2021;61(9):2621–8. Compares pediatric LTOWB receipients to conventional component recipients and shows that LTOWB transfusion did not increase risk of adverse events.

  57. Leeper CM, Yazer MH, Cladis FP, Saladino R, Triulzi DJ, Gaines BA. Cold-stored whole blood platelet function is preserved in injured children with hemorrhagic shock. J Trauma Acute Care Surg. 2019;87(1):49–53.

    Article  PubMed  Google Scholar 

  58. Beno S, Ackery AD, Callum J, Rizoli S. Tranexamic acid in pediatric trauma: why not? Crit Care. 2014;18(4):313.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Collaborators C-t, Shakur H, Roberts I, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010;376(9734):23–32.

    Article  Google Scholar 

  60. Morrison JJ, Dubose JJ, Rasmussen TE, Midwinter MJ. Military application of tranexamic acid in trauma emergency resuscitation (MATTERs) study. Arch Surg. 2012;147(2):113–9.

    Article  CAS  PubMed  Google Scholar 

  61. Sethna NF, Zurakowski D, Brustowicz RM, Bacsik J, Sullivan LJ, Shapiro F. Tranexamic acid reduces intraoperative blood loss in pediatric patients undergoing scoliosis surgery. Anesthesiology. 2005;102(4):727–32.

    Article  CAS  PubMed  Google Scholar 

  62. Pasquali SK, Li JS, He X, et al. Comparative analysis of antifibrinolytic medications in pediatric heart surgery. J Thorac Cardiovasc Surg. 2012;143(3):550–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Song G, Yang P, Zhu S, et al. Tranexamic Acid reducing blood transfusion in children undergoing craniosynostosis surgery. J Craniofac Surg. 2013;24(1):299–303.

    Article  PubMed  Google Scholar 

  64. ∙Eckert MJ, Wertin TM, Tyner SD, Nelson DW, Izenberg S, Martin MJ. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852–858; discussion 858. Retrospective review of pediatric combat trauma patients, which showed a survival benefit with use of tranexamic acid and no increseased risk of VTE or other adverse events.

  65. Hamele M, Aden JK, Borgman MA. Tranexamic acid in pediatric combat trauma requiring massive transfusions and mortality. J Trauma Acute Care Surg. 2020;89(2S Suppl 2):242–5.

    Article  Google Scholar 

  66. Thomson JM, Huynh HH, Drone HM, Jantzer JL, Tsai AK, Jancik JT. Experience in an urban level 1 trauma center with tranexamic acid in pediatric trauma: a retrospective chart review. J Intensive Care Med. 2021;36(4):413–8.

    Article  PubMed  Google Scholar 

  67. ∙Spinella PC, Leonard JC, Gaines BA, et al. Use of antifibrinolytics in pediatric life-threatening hemorrhage: a prospective observational multicenter study. Crit Care Med. 2022;50(4):e382–92.

    Article  PubMed  Google Scholar 

Download references

Funding

No funding was received.

Author information

Authors and Affiliations

  1. Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Insiyah Campwala

  2. Division of Trauma and General Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Christine M. Leeper

  3. Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh, Children’s Hospital of Pittsburgh, Children’s Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA

    Barbara A. Gaines

Authors
  1. Insiyah Campwala
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christine M. Leeper
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Barbara A. Gaines
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

IC, CL, and BG designed the project. IC performed the literature review and drafted the manuscript. CL and BG performed critical revision of the article and approved the final manuscript for submission.

Corresponding author

Correspondence to Barbara A. Gaines.

Ethics declarations

Competing interests

None.

Ethical Approval/Human and Animal Rights

This article does not contain any studies with human or animal subjects performed by any of the authors.

Consent for Publication

Not applicable.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Campwala, I., Leeper, C.M. & Gaines, B.A. The Use of Blood in Pediatric Trauma Resuscitation. Curr Surg Rep 11, 137–143 (2023). https://doi.org/10.1007/s40137-023-00356-x

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40137-023-00356-x

Keywords

Search

Navigation