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An 11-year-old, 30-kg patient presents to the operating room emergently after being hit by a car. He was unconscious at the scene and intubated. He was volume resuscitated and so far has received 40 mL/kg of lactated Ringer’s and 2 units of blood. He remains hemodynamically unstable (heart rate 130, blood pressure 80/35) and has a positive focused assessment with sonography for trauma exam. His head CT scan reveals diffuse edema with no focal bleeding. His cervical spine CT is unremarkable, and he remains in a cervical collar. The plan is to do an exploratory laparotomy for control of bleeding.


Trauma is the leading cause of death in children between 1 and 18 years old. We consider adult patients to have received a massive transfusion when they have received 10 units of blood; in children, several definitions have been used, including >40 or >70 mL/kg.

Recently, adult trauma literature has shown that using a fixed ratio of blood products (1:1:1 PRBC:FFP:plt [packed red blood cells:fresh frozen plasma:platelets) may improve outcomes. This is starting to be applied to pediatric patients, although the mechanism responsible for massive blood loss can be different (ie, more blunt trauma in pediatric patients).

This patient also has a significant head trauma, and his blood pressure should be kept at a level that will ensure adequate cerebral perfusion. An intracranial pressure monitor would be helpful to guide ideal cerebral perfusion pressure.


  • Warm the room.

  • Be ready for transfusion with fluid warmer and blood infusion set; get two large-bore peripheral IVs. Arterial access is desirable but secondary.

  • Ensure that the blood bank is sending adequate amounts of blood products.

  • Consider activating the massive transfusion protocol if present when >40 mL/kg blood loss is anticipated.

  • Give fresh frozen plasma (FFP) and platelets early (ratio close to 1:1:1).

  • Cryoprecipitate (4 mL/kg) should be given to maintain fibrinogen above 1 g/L or for ongoing bleeding after giving one round of PRBC/FFP/plt.

  • Be ready for significant hemodynamic compromise with the laparotomy.

  • Calcium levels should be followed and repleted with transfusion.


Occasionally, the source of bleeding will not be able to be determined, and damage control resuscitation is necessary. This involves packing the abdomen and correcting coagulopathy, acidosis, and hypothermia before going back for a second look.

DOs and DON’Ts

  • ✓ Do warm the operating room and all blood products, as hypothermia is common and will contribute to coagulopathy.

  • ✓ Do use a rapid infusion device.

  • ⊗ Do not wait to activate the massive transfusion protocol if significant bleeding is anticipated.

  • ✓ Do use FFP and platelets early.

  • ✓ Do not forget to replete calcium, 10 mg/kg to maintain ionized calcium above 1 mmol/L.


  • The ...

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