Hemorrhagic Shock Management in Pediatric Trauma - A Comprehensive Clinical Framework (2015–2025)

Pediatric hemorrhagic shock is a primary driver of preventable trauma mortality, often due to failures in early recognition and intervention. This review aims to define an actionable, pediatric-specific clinical framework for managing hemorrhagic shock by synthesizing pivotal advancements over the last decade into an evidence-to-practice guide for clinicians and policymakers. Management has evolved significantly, with a shift away from crystalloid-based resuscitation toward early, blood-first strategies using whole blood or balanced component therapy. Advances in predictive analytics, including machine-learning-enhanced shock indices, have improved early detection. Furthermore, viscoelastic hemostatic assays are increasingly used to guide goal-directed therapy, particularly for fibrinogen replacement, while comprehensive care bundles and simulation-based training are being implemented to improve system-level performance and reduce mortality. Effective management of pediatric hemorrhagic shock requires a proactive, integrated approach. This includes early MTP activation guided by age-adjusted metrics, rapid hemostasis with blood-based resuscitation, targeted correction of coagulopathy using viscoelastic guidance, and diligent management of the "lethal triad." Critical knowledge gaps remain, particularly in prehospital prediction and defining optimal transfusion strategies, highlighting the need for high-quality, pediatric-specific clinical trials.