Damage control resuscitation in severe pediatric trauma. Part I: Limited crystalloids administration, permissive hypotension, balanced transfusion in hemostatic resuscitation

Abstract

Trauma is a leading cause of mortality in the pediatric population. Approximately 50% of pediatric trauma deaths occur within the first 24 hours, with 30% considered preventable or potentially preventable. A significant percentage of these deaths are due to hemorrhage, secondary to the hyperfibrinolytic phenotype of trauma-induced coagulopathy (TIC). The progression to hemorrhagic shock due to trauma in pediatrics is associated with high mortality (36%-50%), which is higher than that reported in adults. Damage control resuscitation (DCR), aimed at controlling TIC through its strategies, has been shown to improve outcomes in the adult population with severe trauma, and has evidence-based clinical practice guidelines available for the management of coagulopathy in trauma patients. In pediatrics, the strategies used in DCR have not yet been fully validated due to the lack of high-quality evidence to support them; however, in the last 10 years, research in this area has increased substantially. The objective of this review is to update the current evidence regarding the relevance of DCR in the pediatric population with severe trauma, focusing mainly on initial medical management, to establish best management practices guidelines for this condition. This first part analyzes the existing evidence regarding crystalloid restriction, permissive hypotension, and hemostatic resuscitation with balanced blood products in the pediatric population with severe trauma.