Fluid and Medication Considerations in the Traumatized Patient
Current Pediatric Reviews
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This article reviews fluid therapy and medications in pediatric trauma. For resuscitation in the setting of hemorrhagic shock, isotonic crystalloid solution is the first-line agent of choice. Colloid solutions offer no additional benefit, introduce possible increased risks and cost more than crystalloids. Blood products, starting with pRBCs, should be introduced after 20-40 ml/kg of crystalloid has been administered if there is ongoing need for volume replacement. The use of a massive transfusion protocol of 1:1:1 (if >30 kg) or 30:20:20 (if <30 >kg) of pRBCs:FFP:platelets is suggested after an initial 30 ml/kg of pRBcs has been administered. Cryoprecipitate should be given for documented low fibrinogen or ongoing bleeding after administration of 1 round of all 3 blood components. For patients at risk of massive hemorrhage, early administration of tranexamic acid with an initial loading dose of 15 mg/kg (maximum 1 g) is recommended. Choice of medication for intubation of the patient with Traumatic Brain Injury (TBI) may best be guided by physiology: in the TBI patient with a high mean arterial pressure, premedication with lidocaine, fentanyl and use of etomidate may be most appropriate, whereas in the hemodynamically compromised patient, use of ketamine alone may be considered. If needed, norepinephrine has been recommended as a temporizing agent for vasopressor support in the setting of fluid-refractory shock. Although controversial, in the setting of significant spinal cord injury, the potential benefits of administering 24-48 hours of steroids (initial 30 mg/kg of methylprednisolone within 8 hours of injury) may outweigh the risks especially in previously healthy pediatric patients.