Page 72 - Journal of Special Operations Medicine - Spring 2017

Table 1 Normal Pediatric Vital Signs by Age
Heart Rate Respiratory Rate Systolic Blood Pressure Diastolic Blood Pressure
Age (bpm) (bpm) (mmHg) (mmHg)
Newborn 90–180 30–50 60 ± 10 37 ± 10
1–5 months 100–180 30–40 80 ± 10 45 ± 15
6–11 months 100–150 25–35 90 ± 30 60 ± 10
12 months 100–150 20–30 95 ± 30 65 ± 25
2–3 years 65–150 15–25 100 ± 25 65 ± 25
4–5 years 65–140 15–25 100 ± 20 65 ± 15
6–9 years 65–120 12–20 100 ± 20 65 ± 15
10–12 years 65–120 12–20 110 ± 20 70 ± 15
13+ years 55–110 12–18 120 ± 20 75 ± 15

can potentially cause a 200mL blood loss. This would the provider should take the cravat and tie a knot
represent 20% of a 10kg child’s total blood volume. around the first one-third of the tube. The cravat should
Providers should be aggressive in controlling site of then be tied high above the injury site of the extremity.
active bleeding through the liberal use of direct pres- It is important to keep the two knots separated by at
sure and by limiting the use of bulky dressings. Often, least one to two hand widths. The tube should then be
bulky dressings do not provide enough direct pressure turned until hemorrhaging has stopped. Once adequate
to tamponade the bleeding; instead, they absorb large hemorrhage control has been achieved, the wound tube
amounts of blood, which can disguise serious bleeding. can then be secured using the excess cravat. In general,
Placement of a single 4 × 4 sterile gauze pad or combat although the data are limited for tourniquet use in chil-
gauze with a gloved hand or fingers is the best tool for dren, the overall recommendation is to use them when
applying constant firm pressure to the site of bleeding. necessary for controlling bleeding sources.

Second-line agents include tourniquets and hemostatic There are also few data on the use of hemostatic agents
agents. There are few data on the use of tourniquets in in pediatrics, especially in the prehospital setting. To
wounded pediatric patients; most of the current guide- date, there are no guidelines for the use of these agents;
lines for pediatric tourniquet use have been extrapolated however, Eckert et al. provided a retrospective review
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from adult patients. In 2012, Kragh et al. provided a of all pediatric trauma admissions to the North Atlantic
6
retrospective review of data from a trauma registry that Treaty Organization Role 3 hospital, Camp Bastion, Af-
yielded an observational cohort of 88 pediatric casual- ghanistan, from 2008 to 2012, and suggested that early
ties at US military hospitals in theater on whom tour- tranexamic acid (TXA) administration may be associ-
niquets were used from 17 May 2003 to 25 December ated with decreased mortality without increased throm-
2009. Study results showed that when tourniquets were boembolic complications. Patients selected to receive
used appropriately, pediatric patients’ survival rates TXA were given a 1g intravenous (IV) bolus with the
were similar to that of adult patients (93%) but that potential for a second infusion if there was evidence of
7% of pediatric patients received tourniquets when they persistent hemorrhage, hyperfibrinolysis, or at physician
were not needed, which suggested that users may need discretion. According to the study, however, no patients
further training on use in pediatric patients. Of the chil- received a second infusion of TXA. Those who received
dren who received tourniquets inappropriately (e.g., no TXA tended to have higher injury severity score, acido-
extremity or external lesions amenable to tourniquet sis, hypotension, and coagulopathy. Once these con-
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placement), 83% died (five of six), which may suggest founders were corrected for, TXA was associated with
that tourniquet use was an act of desperation by the decreased mortality in all patients (odds ratio, 0.3; p =
provider to give the patient any chance of survival. Ad- .03). To date, there are no recommendations on appro-
ditionally, data suggest that although tourniquets were priate dosing regimens for TXA in pediatric trauma pa-
not manufactured specifically for the pediatric patient, tients. In other pediatric surgical settings, there is wide
use of the adult Combat Application Tourniquet is variation in TXA dosing, administration, and monitor-
effective. 12 ing. Further research to discern an appropriate regimen
for TXA administration in pediatric patients is needed.
If application of a manufactured tourniquet is not effec-
tive, the provider should apply a cravat tied tightly on Medics are adequately trained in and have practiced
the extremity. Using a rod or tube with some flexibility, adult IV insertion but have limited experience gaining

50 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017