Graded volume resuscitation for traumatic shock (PLS #400): Scoping Review

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Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: none applicable

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: none applicable

Task Force Scoping Review Citation

Couto TB, Maconochie I, Maconochie I, Aicken R, Atkins DL, Bingham R, Couto TB, de Caen A, Guerguerian AM, Nadkarni V, Ng KC, Nuthall G, Ong G, Reis A ,Schexynader S, Tijssen J Van de Voorde P on behalf of the International Liaison Committee on Resuscitation Pediatric Life Support Task Force(s). Graded volume resuscitation for traumatic shock in Children Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Pediatric Life Support Task Force, 09 January 2020. Available from:

Methodological Preamble and Link to Published Scoping Review

The continuous evidence evaluation process started with a scoping review of pediatric life support conducted by the ILCOR PLS Task Force Scoping Review team.

This scoping review has not yet been published.


Standard care – Intravenous administration of warmed isotonic crystalloid solution as an initial 20 mL/kg bolus, followed by one or two additional 20 mL/kg isotonic crystalloid boluses pending the child’s physiologic response. If the child demonstrates evidence of ongoing bleeding after the second or third crystalloid bolus, 10 mL/kg of packed red blood cells may be given.

Graded resuscitation – This term is not currently used in trauma literature. We assessed permissive hypotension/ hypotensive resuscitation; to titrate and control the blood pressure to less than normal range or controlled resuscitation/restrictive resuscitation; to limit the volume of fluid to be administered or late resuscitation; to restrict the fluid resuscitation until admission to the hospital (early resuscitation is opposite term that means to initiate fluid resuscitation from pre-hospital setting). Damage control resuscitation was not assessed as it typically combines restrictive use of crystalloid fluids and early administration of balanced ratios of packed red blood cells, fresh frozen plasma, and platelets, typically as part of a pediatric mass transfusion protocol, usually associated with pharmacologic adjuncts to safely promote hemostasis (rVIIa or TXA) {Henry 2018 376p}

Scoping Review

This scoping review has not yet been published.


PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: Infants and Children who are in hemorrhagic shock following trauma in any setting

Intervention: Graded volume resuscitation, (now restrictive volume resuscitation)

Comparators: Standard care.

Outcomes: Any clinical outcome.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search from March 2009 (last review done) updated to November 1, 2019.

Search Strategies

2010 search strategy updated, up to November 1, 2019:

Initial search for: "hemorrhagic shock" AND "trauma” AND (infant" OR "children") AND ("resuscitation” OR “ volume resuscitation”) AND ("outcome" OR "ROSC" OR "survival")

Initial search” shock”, “ hemorrhagic” and “wounds and injuries”. Other search “fluid therapy”/ “hypotension”/ “mortality”/ “therapy” and “shock”/ “therapy” and “shock” and “traumatic”/”therapy”

Search in: PubMed, EMBASE, AHA EndNote library, Trypdatabase, Cochrane Library


Shock hemorrhagic and wounds and injuries: 1913 articles

Shock and fluid therapy and hypotension and mortality: 112 articles

Shock/*therapy and shock, traumatic/*therapy: 1556 articles

Fluid therapy and hypotension/mortality/*therapy: 9 articles

Hemorrhagic shock and trauma: 2766

Cochrane: 3 articles


( 'fluid'/exp OR 'fluid') AND hemorrhage AND ('shock'/exp OR 'shock') AND [1990-2009]/py: 2668 articles

('shock'/exp OR 'shock') AND hemorrhage AND wounds AND injury AND [1990-2009]/py: 141 articles

('shock'/exp OR 'shock') AND hemorrhage AND injury AND [1990-2009]/py: 5042articles

('shock'/exp OR 'shock') AND trauma AND ('therapy'/exp OR 'therapy') AND [1990-2009]/py: 13047 articles

AHA EndNote library: No additional articles. Searched on hemorrhagic shock, fluid therapy, trauma, children

Trypdatabase: No additional articles. Searched on hemorrhagic shock, fluid therapy, traumatic shock

Inclusion and Exclusion criteria

Inclusion: Studies addressing hemorrhagic shock following trauma treated with volume and including time to fluid resuscitation

Exclusion criteria:

  • Hypovolemic non hemorrhagic shock
  • Septic shock
  • Cardiogenic shock
  • Other treatments (hypothermia, norepinephrine, vasopressin, hemoglobin-based carrier)
  • Adults/animals, simulation and mannikin studies.

Adult studies are referenced in background and Task Force insights.

References found for full article review: 14

Included pediatric studies: 6

Data tables

Table 1 Pediatric Resuscitation for Traumatic Shock

Table 1 Pediatric Resuscitation for Traumatic Shock



Design, Country



Main findings


{Hussmann 2012 R201}

Germany, retrospective analysis of trauma database matched pair

31 patients for high volume paired with 31 with low volume

Group 1: 1 to 4 years old (small child); Group 2: 5 to 10 years old (school child); and Group 3: 11 to 15 years old (adolescence).

According to the prehospital administered fluid volume the patients were divided into a low-volume group and a high-volume group on the basis of the amount of the prehospital administered volume Group 1: low volume 0 to 500 ml, high volume >500 ml; Group 2: low volume 0 to 1,000 ml, high volume >1,000 ml; and Group 3: low volume 0 to 1,500 ml, high volume >1,500 ml

No differences found on Survival 24hs, or Survival to hospital discharge

{Acker 2014 1852}

USA, Colorado, retrospective review of two trauma databases

384 children, 4-16 years

Volume administered in 24hs; 0-40ml/kg n=114, 40-60 ml/kg n=106 or >60 ml/kg n=164.

In hospital mortality rates were associated with volume of crystalloid resuscitation with mortality rates highest among the high volume group (6.7 vs 0.9% in both low and middle volume group, p<0.0005).

On multivariate analysis LOS in patients in either of the two high volume resuscitation groups was increased by a factor of 1.34 compared to those in the low volume group (p < 0.01). On multivariate analysis, the increased odds of requiring mechanical ventilation were shown between those in the low volume group and the middle volume group (p<0.05), however, this difference was not statistically significant between the low and high volume group (p = 0.08).

No differences on ARF, ARDS, ACS, MOF, UTI or blood stream infection.

{Edwards 2015 330}

Afghanistan and Iraq, retrospective review of Department of Defense Trauma Registry from 2002 to 2012

1,311 injured children 14 years or younger who were admitted to US Military hospitals in Afghanistan and Iraq and required transfusion.

907 patients met criteria for analysis.

224 children received high-volume transfusions (>40ml/kg) of either whole blood or PRBCs in the first 24 hours of admission. Seventy-seven of those patients received massive Transfusions (>70ml/kg).

Increased crystalloid administration was independently associated with increased ICU days, ventilator days, and hospital stay in children requiring large volume transfusions.

Those patients receiving more than 150 mL/kg crystalloid had an 18% mortality versus 10% for those receiving 150 mL/kg or less (p = 0.011).

{Coons 2018 2202}

USA, retrospective chart review of single center level 1 trauma center in in New York

468 pediatric trauma patients 0–18 years old admitted to a

level 1 trauma center from January 2013 to December 2015

200 patients met criteria. Four patient cohorts were established based on volume of fluid administered: <20 ml/kg/day n=45, 20–40 ml/kg/day n=56, 40–60 ml/kg/day n=60, and >60 ml/kg/day n=39.

No change in survival. ICU length of stay and overall length of stay were increased in patients who received more than 60 ml/kg/day in the first 24 h of their hospitalization

(Zhu 2019 epub}

China, retrospective review of single-center children’s hospital.

291 patients with blunt trauma from January 2007 to Apr 2018

Patients were dichotomized into low and high groups depending on the average dose of crystalloid fluid administration with a cut-off point during the first 24 or 48 h. propensity matching was performed using a 1:1 ratio nearest neighbor algorithm to minimize the effect of potential confounders in baseline characteristics, with two groups; <80.15 (mL/kg) (n=132) and > 80.15 (mL/kg) n=132.

Patients who received larger doses of crystalloids were more likely than the low-volume group to be associated with severe anemia (p = 0.033), RBC transfusion (p = 0.016) and longer hospital length of stay (p = 0.008). No difference on mortality.

{Elkbuli 2019 S0022}

USA, retrospective review utilizing level I trauma center registry for pediatric patients in Miami, Florida

320 patients aged <16 y admitted from 2014 to 2017

2 groups; <60 mL/kg/24 h n=219; and ≥60 mL/kg/24 h n= 101

No significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU LOS (1.5 d versus 0.8 d, P=0.004).

Task Force Insights

1. Why this topic was reviewed.

This topic was re-evaluated by the PLS taskforce because it had not been reviewed by ILCOR since 2010.

2. Narrative summary of evidence identified

We identified 6 pediatric studies {Hussmann 2012 R201; Acker 2014 1852; Edwards 2015 330; Coons 2018 2202; Zhu H 2019 epub; Elkbuli 2019 S0022}. All studies are retrospective reviews of trauma registries. One from a national registry {Hussmann 2012 R201}, one from a military database {Edwards 2015 330}, one from a two center registry {Acker 2014 1852} and the other three form single-center registries {Coons 2018 2202; Zhu H 2019 epub; Elkbuli 2019 S0022}. Only one study assessed volume given before hospital arrival {Hussmann 2012 R201}, four studies compare total crystalloid volume in 24h {Acker 2014 1852; Coons 2018 2202; Zhu 2019 epub, Elkbuli 2019 S0022} and one study assessed crystalloid given in patients needing transfusions {Edwards 2015 330}. Only one study reported the critical outcome of survival to 24hs {Hussmann 2012 R201}, with no difference found. None reported survival at 30 days with good neurological outcome. On the critical outcomes of survival to discharge four studies reported no difference {Hussmann 2012 R201; Coons 2018 2202; Zhu 2019 epub; Elkbuli 2019 S0022}. One study reported lower survival to hospital discharge with the high crystalloid group (>60ml/kg/24) vs. low and moderate 0-40 ml or 40-60 ml/kg/24h) {Acker 2014 1852} and one reported lower survival in patients receiving more massive transfusion and more than 150 mL/kg/24h versus those receiving 150 mL/kg or less {Edwards 2015 330}. Five studies reported increased hospital or ICU length of stay in patients that received higher crystalloid volume in the first 24h {Acker 2014 1852; Edwards 2015 330; Coons 2018 2202; Zhu 2019 epub; Elkbuli 2019 S0022}. As all studies are retrospective, and report different interventions, patient populations and outcomes, it is difficult to compare results, though data suggests a possible advantage of lower volume resuscitation.

3. Narrative Reporting of the task force discussions

The taskforce discussed the term “graded resuscitation” which was used in the 2010 evidence review but is not frequently found in trauma publications of the last decade. There was discussion around the definition of hypotensive resuscitation in children (which is not clear) and of other different concepts on trauma resuscitation such as restrictive resuscitation or delayed versus early resuscitation.

Adult data favours restrictive resuscitation and the recommendation is firmly moving towards damage control resuscitation. National Institute for Health and Care Excellence (NICE) trauma guidelines {Kanani 2017 20} and American College of Surgeons Advanced Trauma Life Support guidelines {Henry 2018 376p} both suggest restrictive resuscitation and early use of blood components. The taskforce discussed if it should be the mandate of ILCOR to deliberate on trauma resuscitation. As trauma is a major cause of pediatric mortality and there is still clear lack of evidence guiding best practices, the majority of task force members felt this was an important issue that should be addressed by ILCOR, specially relating to cardiopulmonary resuscitation. The taskforce acknowledges most severe child trauma happens in low income countries, with poorer access to blood components and surgical facilities. In that sense, having a clear guideline on resuscitation for trauma can be life-saving. In many situations the mechanism of severe pediatric trauma includes traumatic brain injury, in which restrictive resuscitation might be deleterious. This results in a relative low number of severe pediatric traumas for which restrictive resuscitation would be indicated. There is a clear need for randomized trials on the subject or, in the absence of that, large trauma registries.

This scoping review has not identified sufficient new evidence to prompt a new systematic review or reconsideration of current resuscitation guidelines/treatment recommendations.

Knowledge Gaps

No RCTs compared intervention with standard care in any patient population

There were few observational retrospective studies identified that evaluated this question in the pediatric population, and there were large methodological differences between studies.

Future studies should document survival/neurologically intact survival to hospital discharge/30days.


Acker SN, Ross JT, Partrick DA, DeWitt P, Bensard DD. Injured children are resistant to the adverse effects of early high volume crystalloid resuscitation. Journal of Pediatric Surgery 2014;49:1852–1855. doi:10.1016/j.jpedsurg.2014.09.034.

Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: A practice management guideline from the Eastern Association for the Surgery of Trauma. Journal of Trauma and Acute Care Surgery 2017;82:605. doi:10.1097/TA.0000000000001333

Coons BE, Tam S, Rubsam J, Stylianos S, Duron V. High volume crystalloid resuscitation adversely affects pediatric trauma patients. J Pediatr Surg 2018;53:2202–2208. doi:10.1016/j.jpedsurg.2018.07.009

Edwards MJ, Lustik MB, Clark ME, Creamer KM, Tuggle D. The effects of balanced blood component resuscitation and crystalloid administration in pediatric trauma patients requiring transfusion in Afghanistan and Iraq 2002 to 2012. J Trauma Acute Care Surg 2015;78:330–335. doi:10.1097/TA.0000000000000469.

Elkbuli A, Zajd S, Ehrhardt JD, McKenney M, Boneva D. Aggressive Crystalloid Resuscitation Outcomes in Low-Severity Pediatric Trauma. J Surg Res 2019. doi:10.1016/j.jss.2019.10.009.

Gilley M, Beno S. Damage control resuscitation in pediatric trauma. Current Opinion in Pediatrics 2018;30:338. doi:10.1097/MOP.0000000000000617.

Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci 2012;2:135–142. doi:10.4103/2229-5151.100890

Henry S. Atls Advanced Trauma Life Support 10th Edition Student Course Manual. 10th ed. ACS American College of Surgeons; 2018.

Hughes NT, Burd RS, Teach SJ. Damage Control Resuscitation: Permissive Hypotension and Massive Transfusion Protocols. Pediatric Emergency Care 2014;30:651. doi:10.1097/PEC.0000000000000217.

Hussmann B, Lefering R, Kauther MD, Ruchholtz S, Moldzio P, Lendemans S, et al. Influence of prehospital volume replacement on outcome in polytraumatized children. Crit Care 2012;16:R201. doi:10.1186/cc11809.

Kanani AN, Hartshorn S. NICE clinical guideline NG39: Major trauma: assessment and initial management. Arch Dis Child Educ Pract Ed 2017;102:20. doi:10.1136/archdischild-2016-310869.

Kua JPH, Ong GYK, Ng KC. Physiologically-guided Balanced Resuscitation: An Evidence-based Approach for Acute Fluid Management in Paediatric Major Trauma. Ann Acad Med Singap 2014;43:595–604.

Tosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg 2016;42:297–301. doi:10.1007/s00068-015-0614-9.

Tran A, Campbell BT. The art and science of pediatric damage control. Semin Pediatr Surg 2017;26:21–26. doi:10.1053/j.sempedsurg.2017.01.005.

Zhu H, Chen B, Guo C. Aggressive crystalloid adversely affects outcomes in a pediatric trauma population. Eur J Trauma Emerg Surg 2019. doi:10.1007/s00068-019-01134-0.

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