Damage control resuscitation is a relatively new resuscitative strategy for patients with severe traumatic hemorrhage. This strategy consists of permissive hypotension and early balanced transfusion, and transfers the patients to subsequent surgery. There is growing evidence on harms of excessive fluids. Since 2013, survival benefit of massive transfusion protocol has been proven in adults. Despite insufficient evidence, pediatric massive transfusion protocols are widely used in North American trauma centers. This review focuses on the concept of damage control resuscitation, and summarizes the relevant pediatric evidence.
Damage control resuscitation (DCR) is a resuscitative strategy for patients with severe traumatic hemorrhage to transfer them to subsequent surgery (
DCR, also known as hemostatic resuscitation, consists of permissive hypotension and early balanced transfusion. With these 2 key components, we can transfer patients with severe traumatic hemorrhage alive to subsequent surgery while minimizing the lethal triad (
The origin of DCR goes back to 1993 when Rotondo et al. [
Permissive hypotension, also known as hypotensive or controlled resuscitation, means a judicious fluid therapy to maintain systolic blood pressure slightly lower than age-adjusted low normal limits (70 + 2 × age in years mmHg). In adults, an arbitrary goal of systolic blood pressure may be 80-90 mmHg (in severe traumatic brain injury [TBI], 90-95 mmHg) [
Excessive fluids are potentially harmful to children in several ways [
Excessive fluids should be avoided in children with severe hemorrhage. Recently, 3 adult systematic reviews show the lack of survival benefit of aggressive fluid therapy compared to permissive hypotension [
Severe TBI is the most common cause of death in childhood injury. In severe TBI, cerebral perfusion pressure (mean arterial pressure - intracranial pressure) should be kept at 50 mmHg or higher to minimize secondary brain injury [
Early balanced transfusion means an empirical transfusion with sufficient amount and balance, mimicking whole blood. Besides TBI, injury can lead to death via hemorrhagic shock and ACOT that can be prevented with sufficient amount and balance of transfusion, respectively. This practice should be performed to children with severe traumatic hemorrhage, prior to recognition of the results of conventional coagulation tests (e.g., prothrombin time).
As a specific method of the early balanced transfusion, MTP denotes a pre-defined multidisciplinary transfusion protocol with the sufficient amount (any blood product ≥ 40 mL/kg/24 hour) and balance (ideally, packed red blood cell [PRBC]: fresh frozen plasma [FFP]:platelet [PLT] = 1:1:1) to provide an efficient DCR [
Children with severe traumatic hemorrhage may need MTP involving FFP infusion that mimics ideal whole blood to minimize fatal ACOT.
Whole blood has been used since World War I because it is readily available in combat settings, and includes all blood components required for oxygen delivery and hemostasis [
ACOT, also known as trauma-induced coagulopathy, is a collective term encompassing a wide range of systemic host defense dysregulation syndromes, manifesting various defects in hemostatic process [
In adults, MTP has proven efficacy for survival and hemostasis that were originally suggested by 2 randomized controlled trials [
In contrast, we have only insufficient evidence on efficacy of P-MTP although many authors had tried to prove it (
Recent literature about P-MTP has added evidence on increasing use of FFP, and its efficacy for hemostasis and survival (
P-MTP is needed by only a portion of children with severe hemorrhage. Most injured children have relatively minor injury mechanisms (e.g., a minor fall) and more robust compensations against hypovolemic shock. Median frequency of activation was 6 times per year (interquartile range, 3-10) even in North American trauma centers running MTPs [
As aforementioned, MTP in adults has a survival benefit without known trigger and ratio of blood products. Despite the insufficient evidence in children, in appropriate candidates, P-MTP should be performed considering its theoretical benefit, proven efficacy in adults, and recent pediatric evidence.
In the U.S. and Canada, P-MTPs are usually activated at the discretion of clinicians [
To investigate the use of DCR in reality, MTP was used as a surrogate for DCR given the more quantitative nature.
As of 2016, 92% of the U.S. and Canadian trauma centers are running P-MTPs [
In 2017, a Korean nationwide survey on MTP was performed at 48 hospitals of which the annual blood product use was 20,000 units or higher [
A Korean single center study on application of DCR to critically injured patients including children (age range, 13-87 years) shows that the patients with an FFP:PRBC ratio ≥ 1:2 had a higher 24-hour survival (72% vs. 97%, P < 0.001) compared to the counterpart without a difference in injury severity [
Children with severe traumatic hemorrhage need DCR that is composed of judicious fluid therapy and early balanced transfusion with sufficient amount and balance to minimize the lethal triad. However, permissive hypotension should be applied cautiously to children with severe TBI. Survival benefit of MTP has been proven in adults. Despite the insufficient evidence in children, DCR, particularly P-MTP, should be performed in appropriate candidates considering its theoretical benefit, proven efficacy in adults, and recent pediatric evidence.
No potential conflicts of interest relevant to this article were reported.
No funding source relevant to this article was reported.
A schematic diagram depicting the concept of DCR (hemostatic resuscitation) consisting of permissive hypotension and early balanced transfusion. It aims to transfer patients with severe traumatic hemorrhage to damage control surgery (or definitive surgery if appropriate) while bypassing or minimizing the lethal triad. As per this concept, such patients need judicious fluid therapy and early empirical transfusion with sufficient amount and balance. DCR: damage control resuscitation.
The lethal triad of severe traumatic hemorrhage. This triangle acts as an obstacle to safe transfer to surgery by increasing mortality, particularly by ACOT. PRBC: packed red blood cell, ACOT: acute coagulopathy of trauma.
DCR differs from the traditional 3 crystalloid boluses followed by PRBC infusion and/or additional transfusion. DCR: damage control resuscitation, PRBC: packed red blood cell, FFP: fresh frozen plasma, PLT: platelet, MTP: massive transfusion protocol.
Anatomic and physiologic features of children relevant to application of damage control resuscitation
Feature | Description |
---|---|
Cause of death | Traumatic brain injury is more common than hemorrhage. |
Hypotensive shock | Infants have a larger blood volume per weight (80 mL/kg; c.f., 70 mL/kg in older children and adults). |
Due to the robust catecholamine-induced compensations against hypovolemic shock, hypotension does not manifest until blood loss exceeds 45% of blood volume. | |
Coagulation profiles | Until 6 months of life, infants have lower concentration of coagulation factors, and quantitatively normal but less functional platelets [ |
Mechanism and severity of injury | Mostly minor (e.g., fall and contusion) |
Recent changes in the Advanced Trauma Life Support reflecting the implications of damage control resuscitation [
Topic | Ninth edition (2012) | Tenth edition (2018) |
---|---|---|
Usual dose of crystalloids | “ |
“ |
No. of crystalloid bolus | “It may be necessary to give |
Removed |
Harms of excessive fluids | “Excessive fluid administration |
“Administering excessive crystalloid solution |
Permissive hypotension | “Balancing the goal of organ perfusion with the |
“Balancing the goal of organ perfusion with the |
Early balanced transfusion | “Once blood product administration is begun, consideration should be given to the need for |
“There had been movement in pediatric trauma centers in the U.S. |
Timing of initial transfusion | “When considering the third 20 mL/kg bolus, the use of |
“ |
Changes in description is written in italic style.
BP: blood pressure, FFP: fresh frozen plasma, PLT: platelet, PRBC: packed red blood cell.
Literature review regarding pediatric MTP in severe injury [
Study | Study design and setting | TBI, % | Overall mortality, % | Survival benefit | MTP | |
---|---|---|---|---|---|---|
Definition |
FFP:PRBC ratio | |||||
Hendrickson et al. [ |
PRO, n = 102 (pre-MTP [TF < 24 h, n = 49, 17 MTPs] vs. post-MTP [n = 53, 26 MTPs]), mean age 6.2 y, 1 level 2 PTC, 09-10 | 66.7 | 30.4 | No | TF ≥ 70 mL/kg | Median 1:1.8 |
Chidester et al. [ |
PRO, n = 55 (8 were non-injured; MTP [n = 22] vs. non-MTP [n = 33]), mean age 9.6 y, 1 level 1 PTC, 09-11 | NA | 45 | No | ≥ 1 × BV or ≥ 0.5 × BV/12 h | Mean 1:2.3 |
Nosanov et al. [ |
RET, n = 105 (MTP), age ≤ 18 y, 1 level 1 TC, 03-10 | 35-38 | 18.1 |
No | TF ≥ 0.5 × BV | < 1:2, 16%; 1:1-2, 47%; ≥ 1:1, 37% |
Edward et al. [ |
RET, n = 907 (“high-vol [≥ 40 mL/kg/d]” TF [n = 224, 77 MTPs), age ≤ 14 y, U.S. military hospitals in Iraq/Afghanistan, 02-12 | 30 | 7 | No |
PRBC or whole blood ≥ 70 mL/kg | ≥ 1:1.25 |
Hwu et al. [ |
RET, n = 235 (pre-MTP [n = 120, 26 MTPs] vs. post-MTP [n = 115, 17 MTPs]), < 18 y, 1 level 1 PTC, 05-14 | 51.5 | 21.7 |
No | PRBC ≥ 40 mL/kg or TF ≥ 80 mL/kg | Mean 0.6 |
Hwu et al. [ |
RET, n = 38 (MTP), < 18 y, 1 level 1 PTC, 06-12 | 71.1 | 52.6 | Yes |
PRBC ≥ 40 mL/kg or TF ≥ 80 mL/kg | Median 0.9 |
Cannon et al. [ |
RET, n = 364 (MTP or death + TF < 24 h), < 15 y, U.S. military hospitals in Iraq/Afghanistan, 01-13 | NA |
18.1 | No | TF ≥ 40 mL/kg | ≥ 1:2, 82% |
Cunningham et al. [ |
RET, n = 465 (MTP), age ≤ 18 y, approximately 70 level 1-2 TCs, 15-16 | 64 | 38 | Yes | TF ≥ 40 mL/kg | < 1:2, 35%; 1:1-2, 38%; ≥ 1:1, 27% |
Noland et al. [ |
RET, n = 110 (MTP or PRBC > 20 mL/kg [or > 2 U]), age ≤ 18 y, 5 level 1 PTCs, 07-13 | NA |
27 | Yes |
“Institutional” or PRBC > 20 mL/kg | 1:1, 36%; 1:2, 32%; 1:3, 33% |
Designated as volume per 24 hours unless otherwise specified.
All mortalities were caused by TBI.
An FFP:PRBC ratio > 0.8 was associated with a higher mortality (18% vs 8%; P < 0.001).
Unknown percentage.
All hemorrhagic deaths occurred in the pre-MTP group.
Only if BIG score ≥ 24 or surgery performed ≤ 6 hours.
Excluding isolated TBI.
Odds of mortality increased by 3.08 (95% confidence interval, 1.10-8.57) with each additional unit of PRBC deviating from a 1:1 ratio.
MTP: massive transfusion protocol, TBI: traumatic brain injury, FFP: fresh frozen plasma, PRBC: packed red blood cell, PRO: prospective, TF: transfusion, PTC: pediatric trauma center, BV: blood volume, RET: retrospective, TC: trauma center.