CME Review ArticleDamage Control Resuscitation: Permissive Hypotension and Massive Transfusion ProtocolsHughes, Naomi T. MD*; Burd, Randall S. MD, PhD†; Teach, Stephen J. MD, MPH‡Author Information Assistant Professor (Hughes), *Division of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, The Children’s Hospital of Philadelphia, Philadelphia, PA; Professor of Surgery and Pediatrics (Burd), †Division of Trauma and Burn Surgery, George Washington University School of Medicine and Health Sciences Chief; Professor of Pediatrics and Emergency Medicine Chair (Teach), ‡Department of Pediatrics, Children’s National Health System, George Washington University School of Medicine and Health Sciences, Washington, DC. The authors and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interest in, any commercial organizations pertaining to this educational activity. Reprints: Naomi Hughes, MD, Division of Emergency Medicine, University of Pennsylvania, Perelman School of Medicine, The Children’s Hospital of Philadelphia 3501, Civic Center Boulevard, CTRB 9th Floor, Room 9122, Philadelphia, PA 19104 (e-mail: [email protected]). Pediatric Emergency Care: September 2014 - Volume 30 - Issue 9 - p 651-656 doi: 10.1097/PEC.0000000000000217 Buy SDC Take the CME Test Metrics Abstract Evidence for changes in adult trauma management often precedes evidence for changes in pediatric trauma management. Many adult trauma centers have adopted damage-control resuscitation management strategies, which target the metabolic syndrome of acidosis, coagulopathy, and hypothermia often found in severe uncontrolled hemorrhage. Two key components of damage-control resuscitation are permissive hypotension, which is a fluid management strategy that targets a subnormal blood pressure, and hemostatic resuscitation, which is a transfusion strategy that targets coagulopathy with early blood product administration. Acceptance of damage-control resuscitation strategies is reflected in recent changes in the American College of Surgeons’ Advanced Trauma Life Support curriculum; the most recent edition has decreased its initial fluid recommendation to 1 L from 2 L, and it now recommends early administration of blood products without specifying any specific ratio. These recommendations are not advocating permissive hypotension or hemostatic resuscitation directly but represent an initial step toward limiting fluid resuscitation and using blood products to treat coagulopathy earlier. Evidence for permissive hypotension exists in animal studies and few adult clinical trials. There is no evidence to support permissive hypotension strategies in pediatrics. Evidence for hemostatic resuscitation in adult trauma management is more comprehensive, and there are limited data to support its use in pediatric trauma patients with severe hemorrhage. Additional studies on the management of children with severe uncontrolled hemorrhage are needed. © 2014 Lippincott Williams & Wilkins, Inc.