Resuscitation should be performed in a swift and goal-oriented manner. One of the worst errors you can make is spending too much time with a bleeding patient in the emergency room and delaying operative hemostasis. In unstable patients, an airway should be secured, good venous access (Table 73.2) obtained by the quickest and simplest technique applicable, and resuscitation commenced. It is usually clear to an experienced surgeon that the patient is not responding to resuscitation, and the trip to the operating room should be undertaken without further delay. The patient must be kept warm, and packed red blood cells and other hematological products should be prepared for. The use of a balanced resuscitation approach with a 1:1 ratio of packed red cells and plasma is gaining momentum but still not proven to improve pediatric outcomes. The decision as to which body cavity or limb needs to be explored is usually clear after examination and initial resuscitation. Chest tubes can be placed with local anesthetic even in uncooperative children and should be used as resuscitative measures to avoid tension pneumothorax or hemothorax. Because of the thin anterior abdominal wall of most children, a large hemoperitoneum is usually clinically obvious. Trips to the computed tomography (CT) scanner are hazardous in this situation, and you will almost always regret them – rarely will you regret the absence of imaging information!

The place of emergency department thoracotomy is an ongoing controversy in the management of the injured patient. I prefer to think of it as a resuscitative thoracotomy (RT), indicating its role as an adjunct to resuscitation when the patient does not respond to conventional resuscitation. Previously, children were assumed to have greater physiological reserve, and hence RT was applied liberally in an attempt to salvage desperate situations, but this usually failed or, even worse, produced survivors with neurologic compromise. Cumulative experience to date indicates that RT should be reserved for the following categories of pediatric patients after penetrating trauma:

Under these circumstances, salvage rates of between 4 and 26 % can be expected, depending on the mechanism of injury and local circumstances. Children with penetrating abdominal injuries who do not respond to resuscitation should be transferred immediately to the operating room for laparotomy. It is my experience that children who receive a thoracotomy followed by laparotomy under these circumstances have a dismal prognosis and are best treated by laparotomy alone.

Whereas one may sometimes deliberate over the decision of the best incision for abdominal access for other conditions, in penetrating trauma the answer is easy (even in small children) – the midline laparotomy (Fig. 73.1). This will give you the best access to the entire abdominal cavity including the aortic hiatus and pelvis; can be easily extended when you inevitably encounter the unexpected (into a sternotomy or thoracoabdominal incision); and heals in a durable and acceptable fashion. If necessary, you can leave the incision open in the context of abdominal compartment syndrome, leaving you the easiest closure later. Remember to prepare and drape the patient from the knees to the chin to allow access to the femoral vessels, neck, and chest if required. Make sure that the operating room is heated to at least 26–28 °C, and keep the patient warm with active warming devices. Mechanical retractors can make the difference between success and failure and should be available from the start. In cases of vigorous bleeding, autotransfusion appears to be a helpful adjunct to these patients’ care.

In most cases, definitive surgery can be performed in children with penetrating abdominal injuries as they are less likely to develop a systemic inflammatory response syndrome (SIRS) or organ dysfunction than their similarly injured adult counterparts and will generally have the physiological reserves to tolerate the additional time on the operating table. In cases with an established coagulopathy and hypothermia, damage control techniques can be lifesaving.