For many of us, we have become conditioned to first resuscitate with crystalloid fluids in shock. This means giving the ‘ole standby of 20mL/kg of normal saline or Lactated Ringer’s solution. A recent multicenter study called this reflexive practice into question.

Timing and Volume of Crystalloid and Blood Products in Pediatric Trauma – An EAST Multicenter Prospective Observational Study
Polites et al.
Journal of Trauma and Acute Care Surgery, 2020

There has been some retrospective evidence that high volume crystalloid fluid resuscitation was associated with longer length of stay (both in the hospital and ICU), as well as a longer time on the ventilator. In general, it has been thought that the crystalloid response plates with a second 20mL/kg bolus. I’ve included these references below (Acker, Coons, and Polites).

What did they do?

This was a multi-institutional (24 center) prospective observational study of pediatric patients <18 years old who sustained injuries and were transported from the scene with an elevated age-adjusted shock index (SIPA) upon arrival. The Pediatric Age Adjusted Shock Index predicts mortality in children with blunt trauma. The main components are; age (4-16 years), maximum heart rate, and minimum systolic blood pressure. MDCalc provides links to the support literature and a great summary of this score that you may not be intimately familiar with.

Patients were screened and included based on their first and second set of vital signs and included if they had an elevated SIPA on either set. Children were excluded for the following reasons:

  • >20% total body surface area burn
  • Isolated burn or inhalation injury
  • Asphyxiation injury
  • Transfer from another facility
  • Transport by private vehicle or police.

Overall the assessed the “volume and timing of prehospital, emergency department, and initial admission resuscitation … including calculation of 20±10 mL/kg crystalloid boluses overall and prior to transfusion.” They then performed a multivariable analysis to identify factors associated with mortality and extended intensive care, ventilator, and hospital days.

What did they find?

There were 712 children evaluated across all 24 centers. The mean age was 7.6 years and the median injury severity score was 9 (range 2-20). The in hospital mortality rate was roughly 1 in 20 (5.3%, 38/712). Other important findings included the following.

  • 311 (43.7%) patients received at least one crystalloid bolus
  • 149 (20.9%) who received blood
  • 65 (9.6%) had massive transfusion activation
  • Half (53.3%) of all patients who received >1 crystalloid bolus required transfusion

Findings in the 41 patients who received blood as the first source of volume:

  • Shorter median time to transfusion (19.8 vs 78.0 minutes, p=.005)
  • Lower total fluid volume (50.4 vs 86.6 mL/kg, p=.033) versus patients who received crystalloid first despite similar ISS (median 22 vs 27, p=.40).

The multivariable analysis showed no association with mortality (p=0.51). Each crystalloid bolus after the first was associated with:

  • Extended ventilator, ICU, and hospital days (all p<0.05)
  • Longer time to transfusion was associated with extended ventilator duration (OR=1.11, p=0.04).

What does this all mean?

In short – we should be wary of giving a second crystalloid bolus beyond the initial 20mL/kg. This study demonstrated increased odds of:

  • Prolonged mechanical ventilation
  • Intensive care length of stay
  • Hospital length of stay
  • Need for a blood transfusion

So, if the injured child needs volume resuscitation consider doing one of the following:

  • Give no more than 20mL/kg of crystalloid before going to blood
  • Consider giving blood as the first volume expander

Importantly, this study noted that because SIPA includes tachycardia as a variable, children who are frightened and in pain make make this assessment tool less helpful in assessing who actually needs an early blood transfusion. Hypotension is a late and ominous finding that one should not wait for. So, until we have a better tool the authors would encourage us to use both an elevated SIPA and the response to a first crystalloid bolus as when to transition to blood. This will require prospective, multi center trials.

This study is limited by the issues noted with the SIPA score, as well by the fact that transfers from other facilities were excluded. They lost half of all possible patients because of the transfer exclusion. Attention must be paid to practices at non-level I trauma centers and educational interventions (like FOAM) to improve them. Finally, there was no usable data on transfusion ratios, viscoelastic monitoring, or some other lesser seen complications because of low numbers of subjects.


Acker et al. Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. J Pediatr Surg. 2014;49(12):1852- 1855.

Coons et al. High volume crystalloid resuscitation adversely affects pediatric trauma patients. J Pediatr Surg. July 2018.

MD Calc: Shock Index, Pediatric Age-Adjusted (SIPA)

Polites et al. Multicenter study of crystalloid boluses and transfusion in pediatric trauma—When to go to blood? J Trauma Acute Care Surg. 2018;85(1):108-112.