Emergency Department, Inpatient, and ICU Clinical Pathway for Children with Blunt Abdominal Solid Organ Injury

Age Adjusted Hemodynamic Parameters

Anything outside the vital signs below is concerning for hemodynamic instability.

Due to the physiologic reserve in children, blood pressure may be maintained despite a significant blood loss. Tachycardia is often the only compensatory method for pediatric patients who cannot increase their stroke volume. Hypotension is a LATE sign typically not present until Class III Hemorrhage (30% blood loss) has occurred.

Heart rate may also be affected by pain, anxiety, medications and hydration status.

Age HR Systolic BP Diastolic BP
Newborn 120 - 160 50 - 70 30 - 60
Infant (1 - 12 mos) 80 - 140 70 - 100 53 - 66
Toddler (1 - 3 yrs) 80 - 130 80 - 110 53 - 66
Preschooler (3 - 5 yrs) 80 - 120 80 - 110 53 - 69
School Age (6 - 12 yrs) 70 - 110 80 - 120 57 - 71
Adolescent (13+ yrs) 55 - 105 110 - 120 66 - 80

Hemoglobin Stability

Stable Hgb is defined as two consecutive stable or up trending Hgb (including admit Hgb)

Fluid and Transfusion Indications

Administer blood rather than crystalloid if hemorrhagic shock is obvious

  Volume Comments
Warmed Isotonic Crystalloid Solution NS or LR 20 mL/kg
  • Monitor response:
    • Improved mental status
    • HR trending to normal range
    • Capillary refill < 2 seconds
    • Good peripheral pulses, skin color, temperature
  • Repeat as clinically indicated
    • Escalate to blood quickly (can be before crystalloid) if concern for hemorrhagic shock
Warmed O negative or type-specific warmed PRBC’s 10 - 20 mL/kg
  • Administer immediately if hemorrhagic shock is obvious
  •  
  • Administer quickly if condition deteriorates and/or signs of shock continue after first crystalloid bolus
  •  
  • Consider initiation of Massive Transfusion Protocol if response to initial colloid resuscitation is poor.
    • Specify if you are requesting Platelets

Indications for Surgical Interventions

Angioembolism-Interventional Radiology (IR)

  • Signs of acute or chronic bleeding despite PRBC transfusion
  • Not indicated for contrast blush on admission CT alone without other indication for intervention (persistent anemia, tachycardia, etc.)
  • IR should be avoided in unstable patients with profound or decompensated shock

Operative exploration-Operating Room