There is little research evidence to underpin clinical guidelines for the management of children with major haemorrhage. In general, principles developed in adult practice have been extrapolated to the care of children (see Chapter 7). Well-rehearsed local protocols, excellent communication with the transfusion laboratory and involvement of appropriate senior staff with paediatric expertise are important elements of successful care.
Emergency group O RhD negative red cells should be rapidly available, with the option of moving to group-specific blood when the identity of the patient and the blood group have been verified. The transfusion laboratory should be informed of the age and (estimated) weight of the patient to guide selection of appropriate blood components. Age-specific components should be used if available in a clinically relevant time frame. Otherwise, the ‘next best’ adult component should be used until specialised products are available. Where red cell:FFP transfusion ratios are employed, the ratio should be based on volume (mL), rather than ‘units’. Once the patient has been stabilised by ‘damage control resuscitation’ and transfusion based on clinical signs, appropriate therapeutic targets (based on rapid return laboratory or near-patient testing) are: Hb 80 g/L; fibrinogen >1.0 g/L; PT ratio <1.5; platelet count >75×109/L.
Based on the CRASH-2 study in adults, the Royal College of Paediatrics and Child Health now recommends the use of tranexamic acid in children after major trauma in a dose of 15 mg/kg (maximum 1 000 mg) infused intravenously over 10 minutes followed by 2 mg/kg/h (maximum 125 mg/h) until bleeding is controlled.