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Initial management steps for all patients include immediate vascular access,
cardiorespiratory monitoring, and administration of oxygen, regardless of oxygen
saturation to maximize oxygen-carrying capacity of the existing RBC mass and plasma.
Unstable patients require multiple sites of vascular access. Peripheral intravenous (IV)
catheters are typically more useful than central lines for rapid volume resuscitation;
intraosseous access may also be used. If transfusion is anticipated, the blood bank
should be notified promptly.
Trauma patients (see Chapter 7 A General Approach to the Ill or Injured Child )
require a multidisciplinary team to complete primary, secondary, and tertiary surveys.
Occult blood loss as discussed above should be considered in all trauma patients. The
use of ultrasound and FAST (focused assessment with sonography in trauma) may be
helpful in assessing for intra-abdominal hemorrhage in the multisystem trauma patient
(see Chapter 131 Ultrasound ). Management is simultaneously directed at immediate
hemodynamic stabilization and efforts to control blood loss through surgical and
catheter-guided embolization strategies as indicated. Patients in uncompensated shock
(hypotension, signs of end-organ dysfunction) require rapid fluid resuscitation via push–
pull, pressure bag, or rapid infuser. Crystalloid fluids are typically available most
quickly and should be used until O-negative blood is available. However, patients with
uncompensated shock due to hemorrhage ultimately require transfusion ( Table 93.2 ).
Hemoglobin changes typically lag behind acute blood loss and are not a useful guide to
initial management. Patients with isolated tachycardia but no other signs of end-organ
dysfunction such as altered mental status, decreased urine output, or poor perfusion
(compensated shock) should be managed based on the severity of the tachycardia,
anticipated trajectory of the blood loss, and the need for embolization or operative
management. Failure to respond to initial crystalloid resuscitation in these patients may
be an indication for transfusion. Traumatic hemorrhage may result in coagulopathy that
could worsen bleeding. Trauma patients requiring massive transfusion will need
additional blood product support with platelets and fresh-frozen plasma (see Table 93.2
) and careful monitoring for electrolyte derangements associated with these treatments.
Tranexamic acid (TXA) is a hemostatic agent used in adult patients presenting with
traumatic hemorrhage; while pediatric data are limited, it may be considered as an

adjunct in an unstable pediatric patient with significant acute hemorrhage.