ECMO-/ECLS

and continued need for blood products warrant consideration for operative
intervention. The operative approach in these cases should be though a
generous laparotomy. If possible, a cell saver should be set up. Appropriate
exploration should be undertaken with four-quadrant packing followed by a
systematic exploration to identify the major source(s) of hemorrhage. In the
trauma bay or the ED, rapid transfusion protocols are being increasingly
implemented in children. Rapid transfusion protocols are utilized with the goal
of 1:1:1 transfusion of packed red blood cells (PRBC), fresh frozen plasma
(FFP), and platelets. In infants and children, this translates to 20cc/kg of PRBC,
FFP and platelets [17].
If the spleen is identified as the source, a splenectomy can be rapidly
performed and will allow for the resuscitation of an unstable patient.
Splenectomy confers to the patient a future risk for post-splenectomy sepsis, an
overwhelming infection caused by encapsulated organisms. For this reason,
vaccination with the 23-valent pneumococcal vaccine, as well as vaccinations
against H. influenzae type B and meningococcus, should be administered after
splenectomy, prior to the patient’s discharge from the hospital. In patients with
splenic injuries, but are not in shock per se, are potential candidates for splenic
salvage operations. Partial splenectomy and mesh splenorrhaphy are
techniques that can save splenic parenchyma. These approaches are time
consuming, and may not appropriate in the unstable patient [18].
A major hepatic injury can be one of the most challenging injuries that a
pediatric surgeon may encounter. Numerous descriptions for the management