A 5-year-old, 23-kg boy was thrown from a sled while riding it down a steep hill approximately 4 hours ago. He complains of generalized abdominal pain and is diaphoretic and pale. Bedside ultrasound is not available. Vital signs: heart rate 120/min; respiratory rate 30/min; blood pressure is not measurable, and femoral pulse is weakly palpable. After two 20 mL/kg boluses of lactated Ringer solution, his condition is unchanged. Your next action is to:
Give a third crystalloid fluid bolus.
Infuse 230 mL 5% albumin.
Perform diagnostic peritoneal lavage.
Infuse 460 mL type-specific whole blood or 230 mL O negative packed red blood cells.
Infuse 690 mL type-specific whole blood or 345 mL O negative packed red blood cells.
Pediatric patients presenting in shock from trauma should receive an initial 20 mL/kg bolus of isotonic crystalloid. This may be repeated once, but if no improvement in the hemodynamic status occurs, immediate transfusion with packed red blood cells, 10 mL/kg, should be performed while preparing for emergent surgery.