Managing Pediatric Hemorrhagic Shock With a Circulation-First Approach

Key Highlights

• Children with hemorrhagic shock may maintain a normal blood pressure until late in their clinical deterioration, making earlier signs such as altered mental status, delayed capillary refill, tachycardia, and low end-tidal carbon dioxide important for recognizing shock.
• A circulation-first approach prioritizes hemorrhage control, vascular access, and appropriate fluid or blood product administration before advanced airway intervention, while maintaining basic airway support.
• Established adult trauma interventions—including blood products, tourniquets, calcium, and tranexamic acid—can generally be applied to children with appropriate adjustments for pediatric dosing and equipment.

In this video Q&A, Peter Antevy, MD, and Mark Piehl, MD, preview their EMS World Expo session on circulation-first resuscitation in pediatric trauma. They discuss recognizing compensated shock before hypotension occurs, prioritizing hemorrhage control and blood products before advanced airway intervention, challenging common misconceptions about pediatric trauma care, and applying established adult trauma principles to children with appropriate adjustments for dosing and equipment.

Additional Resource: https://www.hmpglobalevents.com/emsworldexpo

Transcript

Peter Antevy, MD: I’m Peter Antevy, and I’m affiliated with several emergency medical services agencies in South Florida.

Mark Piehl, MD: I’m Mark Piehl. I’m a pediatric intensive care physician at WakeMed in Raleigh, North Carolina. My one claim to fame is that I’m a friend of Peter Antevy.

Dr Antevy: We’re excited to come to EMS World Expo and discuss this important topic. This session is really about undoing 40 years of muscle memory. We have been taught that when treating a child who is bleeding—or children in general—we must begin with “A” and manage the airway first. It turns out that prioritizing the airway may be the intervention that harms the patient.

During the session, we will address 4 main areas. First, we will discuss how to recognize a critically ill child and how that assessment differs from evaluating an adult. Second, we will review the evidence regarding hemorrhage in children and its treatment. Third, we will explain how agencies can implement protocols that include children. Finally, we will discuss real cases involving children who are alive today because EMS systems treated them with the same high-quality care and urgency afforded to adults. That is the overall theme of the session.

Dr Piehl: Pediatric care has some nuances, but our approach to resuscitation, the order of interventions, and the treatment of the physiology before us are generally the same in adults and children. Clinicians need resources to guide pediatric dosing and equipment sizing, but we want to demystify pediatric trauma care. We also want to help EMS clinicians put interventions in the correct order to achieve the best possible outcomes.

We have traditionally learned that ABC—airway, breathing, and circulation—is the proper order of intervention for any critically ill patient. In children with shock, particularly hemorrhagic shock, we need to reconsider that sequence.

Trauma is the leading cause of death among children, and hemorrhage contributes substantially to that mortality. We therefore need to identify the child in shock and treat that shock rapidly before proceeding to advanced airway interventions, which can be challenging, require extensive training, and potentially worsen the patient’s condition.

The priority should be stopping the bleeding and rapidly administering blood—or plasma, when appropriate—before moving directly to advanced airway management. This does not mean neglecting basic airway care. It means thinking about circulation first, restoring it, and then managing the airway and breathing more definitively.

Dr Antevy: Several myths about pediatric trauma persist. The first is that a normal blood pressure means a child is stable. Children can compensate remarkably well, so clinicians need to understand that blood pressure may remain normal despite significant shock.

The second myth is that children are too small for tourniquets. That is not true. Tourniquets can be used in younger children. EMS clinicians need to have the appropriate equipment and know how to use it, but tourniquets can work in pediatric patients.

A third—and particularly concerning—myth is that blood products are riskier in children. When a child with hemorrhage enters a hospital trauma bay, clinicians administer blood products. Nothing changes physiologically simply because the child has crossed the hospital threshold. Blood can also be administered safely in the prehospital setting. We have military experience spanning decades as well as a growing number of pediatric cases from EMS systems across the country.

Another myth is that EMS agencies do not encounter enough pediatric trauma to justify investing in the necessary resources. That is not true, and one preventable death is too many. During our session, we will explore these and other misconceptions about pediatric emergency care.

Dr Piehl: Children maintain their blood pressure for a long time before they deteriorate. Clinicians therefore need to look for other indications of shock, including altered mental status, delayed capillary refill, tachycardia, or low end-tidal carbon dioxide levels.

We must train ourselves to recognize shock before hypotension develops because once a child becomes hypotensive, that child may be much more likely to die. We need to anticipate deterioration and intervene before cardiac arrest occurs.

Dr Antevy: Too often, clinicians wait until they are behind the eight ball, even though the warning signs have been present. During the presentation, I will preview findings from a study I recently published on the pediatric shock index and how it may help clinicians recognize shock before hypotension occurs.

Dr Piehl: We need to retrain our thinking. A patient in shock may eventually require airway management, but the shock must be addressed first.

In trauma, that may mean administering blood. In traumatic brain injury, plasma may be appropriate. Patients with septic shock or anaphylaxis may require fluids, such as normal saline. Clinicians can administer oxygen, open the airway, and use a bag-valve mask when necessary, but vascular access and the administration of an appropriate volume of fluid or blood should be prioritized before placement of a definitive airway.

Definitive airway management can take time, worsen shock, and introduce additional complications. We need to focus first on what the child’s physiology requires. The same principle applies to adults, but we particularly want clinicians to reconsider the sequence when treating hemorrhagic shock.

Dr Antevy: During the session, we will explain the physiology underlying how advanced airway management may do more harm than good in a child with traumatic or medical shock.

Real-world examples are especially valuable because these are not simulations. They involve actual patients who experienced life-threatening emergencies and were treated by paramedics like those who will be attending the session.

One case involved Izzy, a 6-year-old girl who had undergone a tonsillectomy 6 days earlier. She developed severe bleeding after the procedure and lost consciousness. We have a photograph showing her obtunded in the back of the ambulance.

While the ambulance was still in the driveway, she received 10 mL/kg of low-titer group O-positive whole blood. By the time she reached the emergency department, she was awake and smiling. We have a photograph of that moment as well.

Another case involved Brooklyn, a girl who was thrown from a horse and then injured again when the horse fell on her. She sustained a severe traumatic brain injury and was among the first patients in our system to receive cold liquid plasma in the field. This occurred in December 2024.

She remained in a coma for weeks and subsequently spent approximately a month in rehabilitation. Her prognosis initially appeared poor, but she ultimately experienced a complete neurologic recovery. She received plasma within approximately 15 minutes of the injury, followed by strong hospital and rehabilitation care.

We are now conducting a research project involving more than 150 patients, including children, who received plasma for traumatic brain injury. We hope to publish those data this year. These real-world cases are among the most compelling examples we can share.

Dr Piehl: I will also discuss cases from my experience in the trauma bay and pediatric intensive care unit, as well as cases from EMS agencies with which Peter and I have worked. We will use these examples to encourage audience participation and highlight practical lessons.

Dr Antevy: If an agency is establishing a protocol for prehospital blood product use, children must be included. Within the next 5 to 10 years, I anticipate that most regions will have a program using some type of blood product, such as plasma, packed red blood cells, or low-titer group O-positive whole blood.

Nothing physiologically significant happens when a patient turns 18 that suddenly makes prehospital blood administration appropriate. Pediatric patients should not be excluded from these protocols solely because of their age.

Dr Piehl: The approach we are teaching nearly requires blood products to be available in EMS vehicles. We recognize that not everyone in the audience will be responsible for making that decision, but all of us need to advocate for blood products to be available to prehospital teams. Currently, they are available in only about 4% of US EMS agencies, and Peter and I are working to help increase that proportion.

We also want to demystify the management of severe pediatric trauma. The protocols and pathways used for adults are largely applicable to children as long as clinicians use a circulation-first, circulation-airway-breathing approach.

We will also briefly discuss calcium and tranexamic acid. Blood products, adjunctive treatments, tourniquets, and the other interventions used for adults can also be applied to children, with appropriate pediatric adjustments.

Dr Antevy: We have also had considerable success increasing the speed of blood administration. Even when an ambulance is only a few minutes from the hospital, EMS clinicians may be able to administer 10 or 20 mL/kg of blood to a child—or 1 or 2 units to an adult—before arrival.

Children need their circulating volume restored rapidly. Without timely treatment, they can develop downstream complications such as hypothermia, calcium abnormalities, and disseminated intravascular coagulation.

The overarching message is that EMS clinicians save these lives. Surgeons and emergency physicians provide essential care, but children must arrive at the hospital with a pulse and a chance of survival.

Many of us in EMS have experienced the death of a child despite our efforts. We now have more tools and blood products available to us. We need the will, leadership, and protocols to use them. EMS systems throughout the country are demonstrating that this can be done, and that is the message we hope to convey during our session.

This transcript has been edited for clarity and length.

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