Dr. Matthew Borgman, a Professor of Pediatrics specializing in Critical Care, shares his vast expertise in managing pediatric hemorrhagic shock. He delves into the complexities of recognizing and treating this condition, emphasizing careful fluid resuscitation and the strategic use of blood products. The discussion highlights the advantages of low titer group O whole blood and advanced coagulation testing methods like TEG and ROTEM. Borgman also addresses the challenges of implementing these practices in various healthcare settings, paving the way for improved trauma care.
Pediatric hemorrhagic shock is defined by life-threatening bleeding, where children may lose significant blood volume before showing hypotensive signs.
The debate around crystalloid fluids underlines a preference for blood product resuscitation, emphasizing a need for early availability of these products in emergencies.
Massive transfusion protocols recommend rapid administration of blood components in balanced ratios, enhancing coagulation and improving mortality outcomes in pediatric patients.
Deep dives
Understanding Hemorrhagic Shock in Children
Hemorrhagic shock in children is defined as life-threatening bleeding, which may manifest in various ways, including tachycardia and cool extremities, without necessarily being hypotensive. The assessment includes recognizing that before a child becomes hypotensive, they may have already lost about 30% of their blood volume. This state poses a significant risk, with mortality rates in affected children ranging from 36% to 50%, almost doubling the adult rate. It is crucial to continuously monitor vital signs and overall condition to gauge the child's status accurately and determine the need for immediate intervention.
Fluid Resuscitation Strategies
In managing trauma patients, the use of crystalloid fluids is highly debated, with some experts advocating for minimal to no crystalloid administration due to their association with adverse outcomes such as prolonged ICU stays and complications like ARDS and MODS. Instead, focusing on blood product resuscitation is preferred, suggesting that providing whole blood or balanced transfusions of red blood cells and plasma offers better results. Protocols for early intervention include having blood products readily available, ideally within the emergency department, to decrease time to transfusion. Establishing effective protocols and maintaining close communication with pre-hospital care teams ensure that critical blood products are accessible upon a patient’s arrival.
Massive Transfusion Protocols
Massive transfusion protocols (MTP) are vital for managing children in hemorrhagic shock, requiring rapid administration of blood products at the bedside. Activation of the MTP typically involves delivering a standardized pack that may include a combination of red blood cells, plasma, and platelets, allowing for immediate resuscitation without precise volume measurements. The recommended ratio for plasma to red blood cells aims for a balanced approach, with emerging consensus leaning toward a one-to-one ratio to maintain coagulation and improve mortality outcomes. Understanding local protocols, especially when dealing with pediatric patients, enhances the timely delivery of necessary blood components as the situation dictates.
The Role of Whole Blood in Pediatric Resuscitation
Whole blood transfusion is gaining attention as a potentially optimal strategy for trauma resuscitation due to its comprehensive nature, as it contains red blood cells, plasma, and platelets. This approach might simplify management, addressing coagulopathy effectively by providing all necessary components simultaneously. However, the adoption of whole blood transfusion is challenged by logistical limitations and the need for cultural shifts within medical institutions. Ongoing studies like the MADIC-2 trial aim to provide more data on the effectiveness of whole blood compared to component therapy in this patient population.
Guiding Resuscitation with Monitoring Techniques
Advanced monitoring techniques such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) play a crucial role in guiding resuscitation in trauma patients by assessing coagulation dynamics in real time. These tools provide immediate feedback on clotting ability, allowing clinicians to make informed decisions on when to administer specific blood products based on parameters like clot strength and lysis rates. The rapid analysis can prompt timely interventions such as administering fresh frozen plasma or platelets, significantly impacting patient outcomes. As trauma management continues to evolve, incorporating these monitoring techniques is essential for optimizing care in critically ill pediatric patients.
Matthew A. Borgman, M.D. is a Professor of Pediatrics in the Division of Pediatric Critical Care at the University of Texas Southwestern. Dr. Borgman graduated from Uniformed Services University (USU), he completed Pediatric Residency at Brooke Army Medical Center in 2007, followed by a fellowship in Critical Care at Boston Children’s Hospital. He is a prolific author in pediatric trauma management which has helped redefine the care of injured children. He is also the former national chair of the Pediatric Trauma Society Research Committee and has co-authored the 2022 Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations.
Learning Objectives:
By the end of this podcast, listeners should be able to:
Define pediatric hemorrhagic shock and massive transfusion.
Develop a guideline-based clinical approach to managing a child with hemorrhagic shock.
Explore an expert’s approach to managing a child with hemorrhagic shock where the evidence might not be clear.
References:
Russell et al. Pediatric traumatic hemorrhagic shock consensus conference recommendations. J Trauma Acute Care Surg. 2023 Jan 1;94(1S Suppl 1):S2-S10.
Spinella et al. Transfusion Ratios and Deficits in Injured Children With Life-Threatening Bleeding. Pediatr Crit Care Med. 2022 Apr 1;23(4):235-244.
Gaines et al. Low Titer Group O Whole Blood In Injured Children Requiring Massive Transfusion. Ann Surg. 2023 Apr 1;277(4):e919-e924.
Moore et al. Fibrinolysis Shutdown in Trauma: Historical Review and Clinical Implications. Anesth Analg. 2019 Sep;129(3):762-773.
Roberts et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013 Mar;17(10):1-79.
Dewan et al. CRASH-3 - tranexamic acid for the treatment of significant traumatic brain injury: study protocol for an international randomized, double-blind, placebo-controlled trial. Trials. 2012 Jun 21;13:87.
Spinella et al. Survey of transfusion policies at US and Canadian children's hospitals in 2008 and 2009. Transfusion. 2010 Nov;50(11):2328-35.
Whitton TP, Healy WJ. Clinical Use and Interpretation of Thromboelastography. ATS Sch. 2023 Jan 9;4(1):96-97.
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Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
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