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Permissive hypotension is standard fare when managing the adult trauma patient. In kids, however, hypotension is a bad, bad sign.
Kids, Trauma, and TXA
Rob Orman MD and Tim Horezcko MD
Take Home Points
● Tachycardia indicates shock in pediatric trauma patients.
● Massive transfusion protocol in children happens after transfusion of 40 mL/kg of any blood products.
● Patients who are given two 10mL/kg boluses of packed red blood cells should also be given platelets and plasma in a dose of 10 mL/kg.
● There is evidence demonstrating decreased mortality in pediatric trauma patients with tranexamic acid and it is unlikely to harm.
● Tranexamic acid is given in a dose of 15 mg/kg (up to the adult dose of 1g) bolus over 10 minutes followed by an infusion of 2 mg/kg/h for 8 hours or until they stop bleeding.
● Should we give TXA for kids with trauma? Go for it.
● Children do not tolerate hypotension at all. Hypotension indicates decompensation for shock. They usually will increase their heart rate. If you see a disproportionately elevated heart rate, it is shock. Don’t wait for hypotension. Permissive hypotension is not used in children like adults.
● Most of the trauma in kids is blunt trauma. Most of this is managed medically. It is important for us to know our blood products and adjuncts.
● The first dose of blood products given is 10 mL per kilogram of packed red blood cells. If you have to give another 10 mL/kg of packed red blood cells, you can, but you need to consider if you should also start platelets and plasma. The dose for these is also 10 mL per kg.
● What is the amount indicating massive transfusion in children? 40 mL per kg of any blood product (not just pRBCs).
● The typical circulating volume for a child is only about 80 mL/kg. At 40 mL/kg, you have replaced half of their circulating volume.
● Coagulopathy of trauma is often under-recognized on arrival. About 25% of patients will already have coagulopathy present on arrival.
● Is there any evidence supporting the use of TXA in children? Pediatric surgeons have been giving TXA to children for decades for spinal surgeries, cardiac surgeries and surgery for craniosynostosis. TXA has been shown to be safe in children for surgeries and trauma.
● TXA doesn’t increase the rate of clots in kids. Give it. Give it early. The CRASH-2 inclusion criteria had a systolic blood pressure less than 90 mmHg and heart rate greater than 90. These were pretty sick trauma patients. Tachycardia in a child indicates a sick trauma patient. Give 15 mg/kg up to the adult dose of 1g over ten minutes. Then you can start a drip of 2 mg/kg/h for 8 hours or until they stop bleeding.
● Eckert, MJ et al. 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 Dec;77(6):852-8.PMID: 25423534
○ This study showed that in the 10% of children who received TXA, there was an independent association between TXA and decreased mortality. This study wasn’t optimally designed but is the best available.
Sean E. - February 22, 2019 11:46 AM
Sean E. - June 14, 2019 9:50 PM
In the audio segment you say to give TXA to kids at 15mg/kg over an hour, however I believe it's over 10 minutes like noted in the text summery. Could you please clarify?