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

Age-Adjusted Hemodynamic Parameters

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 (1-2 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 secs 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 PRBCs	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 children with profound or decompensated shock

Operative Exploration-Operating Room

Unstable VS despite PRBC transfusion
Consider Massive Transfusion Protocol

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.