Revista do Colégio Brasileiro de Cirurgiões
https://revistadocbc.org.br/article/doi/10.1590/0100-6991e-2026003625
Revista do Colégio Brasileiro de Cirurgiões
Artigo de Revisão

Coagulopatia do trauma em pacientes pediátricos: uma abordagem baseada em evidências

Trauma-induced coagulopathy in pediatric patients: an evidence-based approach

Leila Costa Volpon; Raíssa Correia Rafael; Ana Paula de Carvalho Panzeri Carlotti

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Resumo

O trauma é o principal problema de saúde pública pediátrica em todo o mundo. A imaturidade do sistema hemostático de crianças aumenta o risco de coagulopatia induzida pelo trauma. Portanto, a partir de uma revisão de literatura foi possível a elaboração de um protocolo clínico. A análise bibliográfica foi realizada com a seleção de revisões sistemáticas, estudos randomizados controlados, observacionais e consensos de especialistas. Os graus de recomendações e os níveis de evidência foram classificados de acordo com os critérios da Universidade de Oxford de 2014. A monitorização laboratorial na primeira hora é de suma importância. Em relação à fluidoterapia, recomenda-se o uso de soluções cristaloides até, no máximo, 20mL/kg, com substituição para os hemocomponentes, assim que estiverem disponíveis. A indicação da transfusão de hemocomponentes deve se basear nos sinais, sintomas e não apenas em resultados laboratoriais. A tromboelastografia pode ser útil para guiar a transfusão de hemocomponentes. Nos pacientes refratários à infusão de 20mL/kg de cristaloides com hemorragia grave, recomenda-se o protocolo de transfusão maciça com as proporções entre plasma e hemácias de 1:1 ou 1:2. Quando disponível, o sangue total deve ser utilizado. Em relação ao ácido tranexâmico, há questões não elucidadas, mas seu uso é recomendado por especialistas em casos de hemorragia grave. A profilaxia para trombose venosa profunda com enoxaparina deve ser considerada nos pacientes maiores de 15 anos com baixo risco de sangramento ou em menores de 15 anos púberes, com traumas graves e baixo risco de sangramento, após estabilização hemodinâmica.

Palavras-chave

Pediatria; Transtornos de Coagulação Sanguínea; Traumatismo Múltiplo

Abstract

Trauma is the leading pediatric public health problem worldwide. Immaturity of the hemostatic system in children increases the risk of Trauma-Induced Coagulopathy (TIC). Therefore, based on a literature review, a clinical protocol was developed. The literature analysis was conducted by selecting systematic reviews, randomized controlled trials, observational studies, and expert consensus statements. Grades of recommendation and levels of evidence were classified according to the 2014 Oxford University criteria. Laboratory monitoring during the first hour is of paramount importance. For fluid resuscitation, crystalloid solutions are recommended up to 20 mL/kg, with a transition to blood components as soon as they become available. The indication for blood component transfusion should be based on clinical signs and symptoms, rather than laboratory results alone. Thromboelastography may be useful to guide blood component transfusion. In patients refractory to 20 mL/kg of crystalloid infusion with severe hemorrhage, a massive transfusion protocol is recommended, with plasma-to-red blood cell ratios of 1:1 or 1:2. When available, whole blood should be used. With regard to tranexamic acid, there are unresolved issues; however, its use is recommended by experts in cases of severe hemorrhage. Deep vein thrombosis prophylaxis with enoxaparin should be considered after hemodynamic stabilization in patients older than 15 years with a low risk of bleeding, as well as in pubertal patients younger than 15 years who have sustained severe trauma and have a low bleeding risk.

Keywords

Pediatrics; Blood Coagulation Disorders; Multiple Trauma

Referências

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