(PT/INR, PTT, platelets) Some centers are now trialing the use of cold-stored whole blood for the resuscitation of bleeding children Controversy remains regarding the role of tranexamic acid (TXA), an antifibrinolytic agent, as an adjunct for the treatment of hemorrhagic shock In bleeding adults, administration of TXA within hours after injury was associated with a survival advantage There is minimal data available in children, but it seems reasonable to treat hemodynamically unstable victims of penetrating trauma with TXA, as well as those with laboratory evidence of fibrinolysis (on viscoelastic testing) Large-bore intravenous catheters are preferable, whether in the upper or lower extremities, to allow rapid infusion of large volumes of fluid during resuscitation Ideally, the blood should be given through a warming device, to avoid significant hypothermia from refrigerated blood products Accessing the femoral vein is acceptable and in fact is a preferred site in children in the rare instances when central access is needed FIGURE 103.1 Initial evaluation and treatment of the child with abdominal trauma FAST, focused abdominal sonography for trauma The American College of Surgeons currently recommends that aggressive fluid resuscitation should be pursued Although there is some suggestion that less rigorous (hypotensive) fluid resuscitation may improve survival by limiting hemorrhage into the peritoneal space, pursuing this strategy in the management of children is still controversial and not part of the approach to the injured child with hypotension As the initial evaluation proceeds, the priorities of management depend on the extent of multisystem injuries and the condition of the patient ( Fig 103.2 ) Patients who are unstable as a result of ongoing blood loss or an expanding intracranial hemorrhage require operative intervention early in the evaluation phase FIGURE 103.2 Management of blunt abdominal trauma FAST, focused abdominal sonography for trauma; CT, computed tomography ( Table 103.2 ) Initial management of the unstable patient Immediate life-threatening injuries, such as airway obstruction, tension pneumothorax, pericardial tamponade, and obvious sources of external blood loss, must be treated promptly upon detection Tourniquet placement for the management of extremity hemorrhage can be lifesaving If significant head trauma has occurred, a determination must be made regarding the need for immediate neurosurgical intervention A rapidly performed CT scan (without IV contrast) of the head is usually sufficient to determine the presence of a hematoma, and the findings will dictate the next steps with regard to evaluation of the abdomen If hemodynamic instability or the need for immediate craniotomy exists and does not allow for CT evaluation of the abdomen ( Fig 103.2 ), a focused abdominal sonography for trauma (FAST examination) should be performed either in the ED or in the operating suite In the presence of a positive FAST examination, laparotomy or laparoscopy and craniotomy proceed simultaneously Finally, if neither thoracotomy nor craniotomy is indicated, emergent laparotomy or laparoscopy is performed when pneumoperitoneum is noted on a plain radiograph or when the patient remains hemodynamically unstable in the face of historical or physical evidence of abdominal trauma With massive hemorrhage, fresh frozen plasma and platelets should be administered along with packed RBCs Initial management of the stable patient Commonly, the injured child can be stabilized in the ED with proper airway and cervical spine management, and with intravenous fluid therapy and blood transfusion A careful secondary survey should then be performed On the basis of history and careful, serial abdominal examinations, CT is indicated when intra-abdominal injuries are suspected ( Table 103.1 ) An abdominal CT scan may be merited based solely on severe force inherent in a particular mechanism of injury, despite an unremarkable physical examination or the absence of abnormal screening laboratory values FAST examination and laboratory studies may help guide the decision making regarding abdominal CT scan Additional management Children with abdominal trauma often need decompression of the stomach; this procedure facilitates examination, may provide information concerning gastric or diaphragmatic injury (bloody aspirate, radiographic evidence of the nasogastric tube in the thoracic cavity), and relieves the discomfort of an ileus Major maxillofacial trauma precludes nasogastric tube placement, but an orogastric tube suffices in these instances Urinary bladder catheterization may provide evidence of genitourinary system injury and is helpful in monitoring urinary output Bladder catheterization is contraindicated when urethral disruption is suspected on the basis of the findings described previously