# Hemorrhagic Shock — GCMD Library living collection

Everything in the library about hemorrhagic shock — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 116 cited statements

## Episodes
### Acute Management
- [Coagulopathy and Analgesia](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793) — podcast · 45:33 · [machine version](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793.md)
- [Trauma II: Solid Organ Injury](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978) — podcast · 37:47 · [machine version](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978.md)
- [ATLS 2021 Pediatric Surgery Update](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549) — podcast · 16:05 · [machine version](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549.md)
- [ATLS 2021 Pediatric Surgery Update](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355) — video · 16:06 · [machine version](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=0) Introduction and Case Presentation: Trauma with Coagulopathy (Ep 1)
- [1:53](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=113) Initial Approach to Coagulopathy Management (Ep 1)
- [6:42](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=402) Viscoelastic Monitoring: Principles and Clinical Application (Ep 1)
- [14:17](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=857) Fibrinolysis Phenotypes and Balanced Resuscitation (Ep 1)
- [19:07](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1147) Massive Transfusion Protocols (Ep 1)
- [19:42](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1182) Multimodal Postoperative Analgesia (Ep 1)
- [25:43](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1543) Sedation Options and Assessment Tools (Ep 1)
- [31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884) ABCDEF Bundle for ICU Management (Ep 1)
- [35:17](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2117) Delirium: Assessment and Management (Ep 1)
- [42:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2571) Delirium Prevention and Closing (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=0) Introduction and ATOMIC Study Background (Ep 2)
- [4:11](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=251) Hemodynamic Status vs Injury Grade (Ep 2)
- [9:56](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=596) Crystalloid Limitation and Early Blood Transfusion (Ep 2)
- [15:28](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=928) Massive Transfusion and Angioembolization (Ep 2)
- [18:16](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1096) ICU Admission Criteria and Monitoring (Ep 2)
- [24:04](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1444) Hospital Length of Stay and Bed Rest (Ep 2)
- [28:31](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1711) Follow-up and Activity Restrictions (Ep 2)
- [35:39](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=2139) Summary and Closing (Ep 2)
- [0:00](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=0) Introduction and Importance of Pediatric Trauma (Ep 3)
- [1:25](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=85) Case Presentation and Initial Assessment Priorities (Ep 3)
- [3:47](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=227) Airway Management in Pediatric Trauma (Ep 3)
- [7:04](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=424) Circulation and Shock Management (Ep 3)
- [11:28](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=688) Neurological Assessment in Pediatric Trauma (Ep 3)
- [13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807) Imaging Guidelines and Conclusion (Ep 3)
- [0:00](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=0) Introduction and Case Presentation: Initial Assessment Priorities (Ep 4)
- [3:53](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=233) Airway Management in Pediatric Trauma (Ep 4)
- [7:05](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=425) Circulation and Shock Management (Ep 4)
- [11:58](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=718) Neurological Assessment and Imaging Decision Rules (Ep 4)
- [15:17](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=917) Conclusion (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In coagulopathic trauma patients, trending coagulation values over time is more clinically useful than a single point measurement. — Vogel (clinical) [Ep 1 · 1:53](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=113)
- Initial assessment of coagulopathy should include review of crystalloid volume, blood product volumes, and transfusion ratios (red cells to plasma to platelets) received during resuscitation. — Vogel (clinical) [Ep 1 · 1:53](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=113)
- Goal-directed hemostatic therapy requires INR, PTT, hemoglobin, platelet count, and ideally viscoelastic monitoring (TEG or ROTEM) to assess functional coagulation. — Vogel (clinical) [Ep 1 · 1:53](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=113)
- Viscoelastic monitoring (TEG/ROTEM) provides global assessment of the entire coagulation system including hemostasis and fibrinolysis by transducing mechanical changes in clotting blood into electrical signals. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Viscoelastic tests measure four phases: time to clot formation (factor function), amplification rate (fibrinogen function), clot strength (platelet function), and fibrinolysis. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Prolonged clot formation time on viscoelastic monitoring indicates factor deficiency and should be treated with plasma. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Abnormal amplification phase (alpha angle) on viscoelastic monitoring indicates fibrinogen dysfunction and should be treated with cryoprecipitate or fibrinogen concentrate. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Reduced clot strength (maximal amplitude on TEG) indicates platelet dysfunction and can be treated with platelet transfusion or DDAVP in specific populations like end-stage renal disease patients. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Rapid drop-off in clot strength on viscoelastic monitoring indicates hyperfibrinolysis and may warrant antifibrinolytic therapy with tranexamic acid or aminocaproic acid. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Tranexamic acid has been widely used in adults for trauma-associated hyperfibrinolysis and is being used increasingly in children. — Vogel (clinical) [Ep 1 · 7:10](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=430)
- Viscoelastic monitoring results are available within 5-15 minutes, compared to 30-45 minutes for conventional coagulation tests (PT/INR/PTT). — Vogel (clinical) [Ep 1 · 11:42](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=702)
- Severely injured children exhibit two fibrinolytic phenotypes: hyperfibrinolysis (rapid fibrinolysis contributing to coagulopathy) and fibrinolytic shutdown (smaller percentage). — Vogel (clinical) [Ep 1 · 14:38](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=878)
- Tranexamic acid may be beneficial in hyperfibrinolytic patients but potentially detrimental in fibrinolytic shutdown patients by increasing hypercoagulability. — Vogel (clinical) [Ep 1 · 14:38](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=878)
- In adults, balanced resuscitation with 1:1:1 ratio of red cells to plasma to platelets improves mortality based on prospective observational studies and randomized trials. — Vogel (clinical) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- Balanced resuscitation in adults improves multiple ICU outcomes including kidney injury, ventilator duration, ICU length of stay, and infection rates. — Vogel (clinical) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- Balanced resuscitation achieves coagulopathy control more efficiently with less overall blood product volume despite appearing to use more products. — Vogel (clinical) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- In pediatric trauma, retrospective studies using National Trauma Databank and TQIP show that 1:1 ratio of red cells to plasma provides improved outcomes. — Vogel (epidemiological) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- The ATOMIC Group published a study of over 100 severely injured pediatric trauma patients showing best outcomes and survival with resuscitation closer to 1:1:1 balanced ratio. — Vogel (epidemiological) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- Standard of care for hemostatic resuscitation in 2019 is balanced resuscitation with 1:1:1 ratio of red cells, plasma, and platelets. — Vogel (guideline) [Ep 1 · 16:16](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=976)
- Massive transfusion protocols should deliver blood products in 1:1:1 ratio, and this is part of American College of Surgeons Committee on Trauma verification standards for trauma centers. — Vogel (guideline) [Ep 1 · 19:07](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1147)
- Multimodal approach to postoperative analgesia has substantial benefits and should include narcotics, non-narcotics, regional techniques, and non-pharmacologic interventions. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Partnering with anesthesia pain service teams and pharmacists is valuable for managing complex postoperative pain in pediatric patients. — Vogel (opinion) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Non-steroidal anti-inflammatory medications (IV Toradol or oral NSAIDs) help minimize narcotic use and can decrease postoperative complications like ileus. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Regional analgesia techniques including epidural catheters and ultrasound-guided nerve blocks are effective for managing incisional pain and reducing intraoperative and postoperative opioid use. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Indwelling analgesic catheters that deliver slow-release local anesthetics into surgical wounds have been shown to be helpful for large incisions. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Gabapentinoids (pregabalin and gabapentin) are useful components of multimodal pain management. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Non-pharmacologic therapies for pain and distress include creating child-friendly environments, supporting families, pet therapy, and augmented virtual reality devices for procedures like dressing changes in burn patients. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- When children are less stressed, their pain tends to be more manageable. — Vogel (clinical) [Ep 1 · 19:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1196)
- Most intubated postoperative patients receive combination sedative therapy with benzodiazepines (midazolam or lorazepam) plus low-dose narcotic infusions (fentanyl, morphine, or dilaudid). — Vogel (clinical) [Ep 1 · 25:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1556)
- Dexmedetomidine (Precedex) is used increasingly for sedation, particularly in congenital heart/cardiac populations, and is helpful for decreasing anxiety associated with intubation. — Vogel (clinical) [Ep 1 · 25:56](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1556)
- Validated pain assessment tools exist across all pediatric ages including FLACC (Faces, Legs, Activity, Cry, Consolability) for preverbal children, validated in surgery, trauma, cancer, and other disease processes. — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- Other validated pediatric pain scales include Faces Pain Scale Revised, Visual Analog Scale (VAS), Color Analog Scale (CAS), and Non-Communicating Children's Pain Checklist (with postoperative version). — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- Visual Analog Scale and Color Analog Scale tend to be better received than Faces Pain Scale in pediatric patients. — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- Richmond Agitation Sedation Score (RASS) is the most commonly employed sedation assessment technique in adults. — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- State Behavioral Score (SBS) is a commonly used sedation assessment score in pediatric ICU patients. — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- Goal-directed sedation aims to keep patients comfortable but not comatose and not overly agitated, allowing them to wake up, interact, and be assessed. — Vogel (clinical) [Ep 1 · 27:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1671)
- The Society of Critical Care Medicine's ABCDEF bundle is an evidence-based approach for ICU management, extensively studied in adults and increasingly used in pediatric ICUs over the past five years. — Vogel (guideline) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- The ABCDEF bundle components are: A (assess and manage pain), B (spontaneous awakening and breathing trials), C (choice of analgesia and sedation), D (delirium assessment, prevention, management), E (early mobility and exercise), F (family engagement). — Vogel (guideline) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- Daily spontaneous awakening trials (sedation holidays) and spontaneous breathing trials in appropriate patients decrease duration of sedation, mechanical ventilation, and ICU stay, improving overall outcomes in both adults and children. — Vogel (clinical) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- Most ICUs have escalation and de-escalation sedation protocols developed with hospital pharmacists, often unique to the ages and patient populations of that institution. — Vogel (clinical) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- Minimizing benzodiazepine use is important because benzodiazepines contribute to development of delirium. — Vogel (clinical) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- Benzodiazepine-sparing agents like dexmedetomidine (Precedex) are important for reducing delirium risk. — Vogel (clinical) [Ep 1 · 31:24](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=1884)
- Approximately 40% of pediatric ICU patients will experience delirium at some point during their ICU stay, with incidence increasing the longer children remain in the ICU. — Vogel (epidemiological) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Delirium is a waxing and waning change in mental status. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Risk factors for pediatric delirium include age less than 2 years, mechanical ventilation, benzodiazepine use, narcotic use, and physical restraints. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Validated delirium assessment tools include CAM-ICU (Confusion Assessment Method for ICU), pediatric CAM-ICU, preschool CAM-ICU (developed at Vanderbilt), and CAP-D (Cornell Assessment of Pediatric Delirium). — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Delirium assessment requires first assessing sedation level; comatose patients cannot be reliably assessed for delirium using screening tools. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Delirium screening tools assess components including appropriate eye contact, purposeful actions, awareness of surroundings, ability to interact with family/caregivers, and ability to communicate. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Positive delirium screening does not definitively diagnose delirium; patients may be uncomfortable from uncontrolled pain, worsening illness, sepsis, or ventilator dyssynchrony requiring detailed clinical assessment. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Non-pharmacologic delirium management includes environmental modifications: maintaining sleep-wake cycles with lights-on during day and lights-off at night, family presence, child life services, and pet therapy. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Melatonin can be effective for managing sleep difficulties in ICU patients as part of delirium management. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Atypical antipsychotics, particularly risperidone started at low dose and titrated up, can be helpful in managing delirium. — Vogel (clinical) [Ep 1 · 36:04](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2164)
- Delirium prevention requires addressing underlying medical needs (infection control, early cultures/antibiotics when indicated), family involvement, and maintaining normal sleep-wake cycles and routines as much as possible. — Vogel (clinical) [Ep 1 · 42:51](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=2571)
- The priorities for evaluating a small child with multi-system trauma are the same as for an adult patient - airway, breathing, and circulation. — Rich Falcone (clinical) [Ep 4 · 2:51](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=171)
- Pediatric patients have more pliable chests, so ribs don't necessarily break, but they can have significant pulmonary contusions and other injuries without obvious chest wall findings. — Rich Falcone (clinical) [Ep 4 · 3:58](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=238)
- Pediatric patients are more susceptible to tension pneumothorax because their mediastinum is more mobile and shifts more easily in response to tension. — Rich Falcone (clinical) [Ep 4 · 4:16](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=256)
- Pediatric patients have large tongues and large heads; when laid on a backboard, the large occiput flexes the head forward and can obstruct the airway. — Rich Falcone (clinical) [Ep 4 · 5:17](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=317)
- True pediatric backboards have a cutout for the head or a built-in bump to keep the torso higher and maintain ear-in-line-with-shoulder alignment. — Rich Falcone (clinical) [Ep 4 · 5:29](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=329)
- ATLS recommends needle cricothyroidotomy for children under 10 years old and surgical cricothyroidotomy for those over 10. — Rich Falcone (guideline) [Ep 4 · 6:13](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=373)
- The choice between needle and surgical cricothyroidotomy depends partly on what the provider is most comfortable with; saving the child's life with potential tracheal damage is better than death from inaction. — Rich Falcone (opinion) [Ep 4 · 6:25](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=385)
- Cricothyroidotomy (needle or surgical) is not a definitive airway; it buys time to get to the OR for formal tracheostomy. — Rich Falcone (clinical) [Ep 4 · 6:45](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=405)
- A 10 mL syringe with IV catheter can be used for needle cricothyroidotomy and connects directly to an Ambu bag. — Rich Falcone (clinical) [Ep 4 · 7:09](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=429)
- When performing needle cricothyroidotomy, you must allow for exhalation, not just continuous insufflation. — Rich Falcone (clinical) [Ep 4 · 7:18](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=438)
- The old ATLS protocol was to give two 20 mL/kg crystalloid boluses before considering blood products. — Rich Falcone (guideline) [Ep 4 · 8:54](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=534)
- Current ATLS teaching is to give one 20 mL/kg crystalloid bolus, and if there is transient or no response, move directly to blood products (10 mL/kg). — Rich Falcone (guideline) [Ep 4 · 9:05](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=545)
- Pediatric blood volume is calculated as weight in kilograms times 80 mL (infants differ slightly). — Rich Falcone (clinical) [Ep 4 · 10:21](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=621)
- A 12 kg child has a total blood volume of approximately 1 liter; a 25 kg child has approximately 2 liters. — Rich Falcone (clinical) [Ep 4 · 10:28](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=628)
- Massive transfusion protocols have been proven to help in adults and there is data supporting their use in pediatrics as well. — Rich Falcone (clinical) [Ep 4 · 10:55](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=655)
- Once a massive transfusion protocol is activated, blood products continue to arrive automatically until the protocol is deactivated; the key is remembering to call and stop it. — Rich Falcone (clinical) [Ep 4 · 11:04](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=664)
- Glasgow Coma Scale can be performed in nonverbal children; they do not automatically receive zero or low verbal scores if they cannot talk normally for their age. — Rich Falcone (clinical) [Ep 4 · 12:11](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=731)
- For nonverbal children on GCS verbal assessment: babbling/nonsense appropriate for age receives full score, irritable crying scores 4, moaning scores 2, and no response is most concerning. — Rich Falcone (clinical) [Ep 4 · 12:25](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=745)
- The most concerning neurological sign in a young trauma patient is a child who does not cry or respond to painful stimuli like IV or IO placement, or a child who stops crying suddenly. — Rich Falcone (clinical) [Ep 4 · 12:42](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=762)
- Children have more diffuse brain injuries in general than adults. — Rich Falcone (clinical) [Ep 4 · 13:05](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=785)
- Child abuse is the most common cause of severe head injury in children less than 2 years old. — Rich Falcone (epidemiological) [Ep 4 · 13:10](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=790)
- Children are more at risk for head injury because of large heads, soft skulls, and tendency to fall on their heads, leading to diffuse rather than focal injuries. — Rich Falcone (clinical) [Ep 4 · 13:11](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=791)
- A multi-institutional algorithm for blunt abdominal trauma identifies approximately 35% of patients at very low risk (0.6%) of intraabdominal injury if they have no abdominal pain, no abdominal wall trauma/tenderness/distension, normal chest X-ray, AST less than 200, and normal pancreatic enzymes. — Rich Falcone (clinical) [Ep 4 · 14:28](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=868)
- Having one positive criterion on the abdominal trauma algorithm does not mandate CT but stratifies risk; having multiple positive criteria increases risk further. — Rich Falcone (clinical) [Ep 4 · 15:16](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=916)
- The priorities when evaluating a small child with multi-system trauma are the same as for an adult patient: airway, breathing, circulation (ABCs). — Rich Falcone (clinical) [Ep 3 · 2:44](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=164)
- Pediatric patients have more pliable chests so ribs don't necessarily break, but they can have a lot of pulmonary contusions and other injuries. — Rich Falcone (clinical) [Ep 3 · 3:58](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=238)
- Pediatric patients have a more mobile mediastinum that will shift more easily in response to tension pneumothorax compared to older patients. — Rich Falcone (clinical) [Ep 3 · 4:20](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=260)
- Airway management should follow a stepwise approach starting with simple maneuvers like jaw thrust before progressing to more invasive interventions. — Rich Falcone (clinical) [Ep 3 · 5:06](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=306)
- Pediatric patients have big tongues and big heads; when laid on a backboard, the large occiput flexes the head forward and can obstruct the airway. — Rich Falcone (clinical) [Ep 3 · 5:06](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=306)
- Some pediatric backboards have a cutout for the head or a bump to keep the torso higher and maintain ear-in-line-with-shoulder positioning. — Rich Falcone (clinical) [Ep 3 · 5:06](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=306)
- ATLS guidelines recommend needle cricothyroidotomy for patients under 10 years old and surgical cricothyroidotomy for patients over 10. — Rich Falcone (guideline) [Ep 3 · 6:02](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=362)
- Provider comfort level matters in cricothyroidotomy choice; saving a life with potential tracheal damage is better than death from inaction. — Rich Falcone (opinion) [Ep 3 · 6:02](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=362)
- Pediatric blood volume can be calculated as weight in kilograms times 80 mL. — Rich Falcone (clinical) [Ep 3 · 10:15](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=615)
- A 12 kg child's entire blood volume is approximately one liter; a 25 kg child has approximately 2 liters. — Rich Falcone (clinical) [Ep 3 · 10:15](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=615)
- Massive transfusion protocols have been proven to help, with more data in adults but also data supporting use in pediatrics. — Todd Ponsky (clinical) [Ep 3 · 10:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=657)
- Once a massive transfusion protocol is activated, blood products continue to arrive automatically until the protocol is stopped; providers must remember to deactivate it. — Todd Ponsky (clinical) [Ep 3 · 10:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=657)
- Thromboelastography (TEG) can guide transfusion management if readily available at the institution. — Todd Ponsky (clinical) [Ep 3 · 10:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=657)
- Glasgow Coma Scale can be assessed in nonverbal children; they should not automatically receive a low verbal score just because they cannot talk. — Rich Falcone (clinical) [Ep 3 · 12:09](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=729)
- For nonverbal children, if babbling or saying nonsense is normal for their age, they receive full verbal score; if irritable and crying, they get a 4; if moaning, a 2; if doing nothing, that is most concerning. — Rich Falcone (clinical) [Ep 3 · 12:09](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=729)
- A young child who does not cry in response to IV stick or IO placement, or who stops crying suddenly, is most concerning from a neurostatus perspective. — Rich Falcone (clinical) [Ep 3 · 12:09](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=729)
- Children have more diffuse brain injuries in general than adults. — Rich Falcone (clinical) [Ep 3 · 12:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=777)
- Child abuse is the most common cause of severe head injury in children less than 2 years old. — Rich Falcone (epidemiological) [Ep 3 · 12:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=777)
- Children are more at risk for head injury because of big heads, soft skulls, and tendency to fall on their heads. — Rich Falcone (clinical) [Ep 3 · 12:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=777)
- ATOMIC consortium started around 2010 as a multi-center prospective study, initially with 5 hospitals expanding to 10, to develop evidence-based algorithms for solid organ injury management — David Notrica (clinical) [Ep 2 · 2:11](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=131)
- Hypotension is a late finding in pediatric hemorrhagic shock; almost half of patients requiring early transfusion are not hypotensive — David Notrica (clinical) [Ep 2 · 6:36](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=396)
- Shock index pediatric adjusted (SIPAA) cutoffs: ages 4-6 greater than 1.2, ages 7-12 greater than 1.0, ages 13+ greater than 0.9. Shock index identifies patients NOT in shock with high sensitivity but has lower specificity — David Notrica (clinical) [Ep 2 · 8:38](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=518)
- When a hypovolemic pediatric patient arrives, you know they have bled but often cannot determine if they are still bleeding until you give them blood and observe their response — David Notrica (clinical) [Ep 2 · 7:47](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=467)
- After 20 mL/kg of crystalloid, blood transfusion should be initiated if non-operative management is desired and good outcomes are the goal — David Notrica (clinical) [Ep 2 · 12:00](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=720)
- Viscoelastic assays (TEG/ROTEM) for directed component therapy are theoretically superior to ratio-driven massive transfusion, but definitive pediatric evidence requires a randomized controlled trial comparing the approaches — David Notrica (opinion) [Ep 2 · 14:35](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=875)
- Angioembolization is safe in pediatric blunt solid organ injury. For splenic injury, no embolized patients in the ATOMIC study went on to fail non-operative management — David Notrica (clinical) [Ep 2 · 16:08](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=968)
- Many patients with hepatic injury who underwent angioembolization still required laparoscopy or washout for bile complications or hemoperitoneum management, though embolization was helpful in converting active bleeding to manageable complications — David Notrica (clinical) [Ep 2 · 17:20](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1040)
- Many patients with contrast extravasation on CT will stop bleeding spontaneously without angioembolization — David Notrica (clinical) [Ep 2 · 16:08](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=968)
- Grade 5 solid organ injuries should be admitted to ICU based on injury grade alone, but grade 1-4 injuries can be managed on the floor if hemodynamically stable — David Notrica (clinical) [Ep 2 · 18:23](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1103)
- In renal injury, bed rest makes no difference in outcomes whether patients are walking or on strict bed rest — David Notrica (clinical) [Ep 2 · 20:22](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1222)
- Hemodynamically stable patients with no signs of bleeding can be safely discharged after 18 hours of observation, as patients who fail non-operative management fail early — David Notrica (clinical) [Ep 2 · 22:00](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1320)
- Serial hemoglobin monitoring is not necessary for stable patients; hemoglobin can decrease due to lab error, dilution from IV fluids, or incorrect blood draw technique. Physical examination and vital signs are superior indicators of ongoing bleeding — David Notrica (clinical) [Ep 2 · 24:03](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1443)
- Half of patients who fail non-operative management do so because they develop peritonitis, not because of continued bleeding — David Notrica (clinical) [Ep 2 · 24:27](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1467)
- Telephone follow-up is effective for low-grade injuries; many patients with low-grade injuries never showed for in-person clinic appointments, and telephone follow-up prevents additional missed school days — David Notrica (clinical) [Ep 2 · 24:41](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1481)
- In-person follow-up visits for solid organ injury have limited utility; patients who needed additional imaging or therapy all presented back to the emergency room with symptoms rather than being identified at routine follow-up — David Notrica (clinical) [Ep 2 · 24:41](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1481)
- Studies performing routine ultrasounds found many pseudoaneurysms, but the number was discordant with actual delayed bleeding or complications, indicating that asymptomatic pseudoaneurysms rarely lead to clinically significant problems (estimated less than 10%, possibly much lower) — David Notrica (clinical) [Ep 2 · 27:27](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1647)
- Activity restrictions default to APSA recommendation of grade-plus-two-weeks (e.g., grade 4 injury restricted for 6 weeks), though this is based on expert opinion rather than scientific evidence — David Notrica (guideline) [Ep 2 · 28:53](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1733)
- Children with solid organ injury can return to school but should change classes 5 minutes before other students to avoid hallway contact and should not participate in gym or physical education — David Notrica (clinical) [Ep 2 · 28:53](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1733)
- Early recurrent hypotension (patient responds to initial resuscitation, becomes stable, then becomes unstable again before reaching ICU) represents failure of non-operative management and requires operation or angioembolization — David Notrica (clinical) [Ep 2 · 35:38](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=2138)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Dr. Vogel completed fellowships in both pediatric surgery and surgical critical care, with research interests in viscoelastic monitoring, goal-directed hemostatic resuscitation, massive transfusion, and optimizing anticoagulation/ventilation during ECLS. — Alexander Gibbons summarizing the discussion [Ep 1 · 0:00](https://qa.library.globalcastmd.com/watch/coagulopathy-and-analgesia-1793?t=0)
- Trauma and trauma-related injuries are the number one killer of pediatric patients. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 4 · 0:30](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=30)
- Intraosseous (IO) access can be placed in the tibia, humeral head, or distal femur; sternal IO is avoided in children though used in adults. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 4 · 8:28](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=508)
- For a child to show signs of hemorrhagic shock (both tachycardia and hypotension), they must lose about half their total blood volume. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 4 · 9:56](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=596)
- Over 75% of pediatric trauma deaths are due to head injuries. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 4 · 11:58](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=718)
- There are validated clinical decision rules for determining when head CT is not necessary in pediatric trauma, with different criteria for children under 2 versus over 2 years old. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 4 · 13:41](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=821)
- In the low-risk abdominal trauma group identified by the algorithm, 0.0% required intervention for intraabdominal injury. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 4 · 15:00](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-13355?t=900)
- Trauma and trauma-related injuries are the number one killer of pediatric patients. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 0:08](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=8)
- MIST stands for mechanism of injury, injuries identified, signs and symptoms, and treatments. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 1:40](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=100)
- Cricothyroidotomy is not a definitive airway; it buys time to get to the OR for formal tracheostomy. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 6:57](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=417)
- For needle cricothyroidotomy, a 10 mL syringe with IV catheter can connect to an Ambu bag for ventilation. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 7:04](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=424)
- Intraosseous (IO) access can be placed in the tibia, humeral head, or distal femur. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 8:26](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=506)
- The old ATLS protocol was to give 20 cc/kg crystalloid bolus, assess response, give another 20 cc/kg, and only then use blood products. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 8:54](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=534)
- Updated ATLS guidelines recommend one crystalloid bolus at 20 cc/kg, and if there is transient or no response, proceed directly to blood products at 10 cc/kg. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 8:54](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=534)
- For a child to start showing signs of hemorrhagic shock, they would have to lose about 50% of their total blood volume. — Ellen Encisco summarizes what Dr. Rich Falcone said [Ep 3 · 10:07](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=607)
- Over 75% of pediatric trauma deaths are due to head injuries. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 11:56](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=716)
- Validated algorithms exist to determine when head CT is not needed in pediatric trauma, with different criteria for children younger than 2 versus older than 2. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- For children younger than 2, head CT may not be needed if the child is not acting different per parents, has no skull fracture, and meets other criteria. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- For children older than 2, additional head CT decision criteria include history of vomiting and signs of basilar skull fracture. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- A multi-institutional algorithm for blunt abdominal trauma uses criteria including abdominal pain, abdominal wall trauma/tenderness/distension, abnormal chest X-ray, AST greater than 200, and abnormal pancreatic enzymes. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- If all blunt abdominal trauma algorithm criteria are negative (approximately 35% of patients), the risk of intraabdominal injury is very low at 0.6%, with 0.0% requiring intervention. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- Having one positive criterion on the blunt abdominal trauma algorithm does not mandate CT but increases risk; multiple positive criteria further increase risk. — Rod Gerardo summarizes what Dr. Rich Falcone said [Ep 3 · 13:27](https://qa.library.globalcastmd.com/watch/atls-2021-pediatric-surgery-update-4549?t=807)
- Arkansas researchers (Sam Smith) and Sean St. Peter demonstrated that patients can be managed based on hemodynamic status rather than CT injury grade, challenging the original grade-based consensus approach developed by Steve Stilanos — David Notrica summarizing a resource [Ep 2 · 4:27](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=267)
- ATLS previously recommended 60 mL/kg of crystalloid before blood transfusion, but adult literature showed excessive crystalloid dilutes the benefit of 1:1:1 resuscitation and reduces non-operative management success — David Notrica summarizing a resource [Ep 2 · 10:31](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=631)
- John Holcomb's work showed that early blood transfusion reduces the number of patients progressing to massive transfusion protocol requirements — David Notrica summarizing a resource [Ep 2 · 12:00](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=720)
- The threshold for failure of non-operative management is 40 mL/kg of all blood products, based on data from the military experience showing increased need for operation and mortality above this threshold — David Notrica summarizing a resource [Ep 2 · 25:40](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1540)
- Bed rest was never included in the original APSA protocols for solid organ injury management, though it became culturally embedded in practice without evidence — David Notrica summarizing a resource [Ep 2 · 20:22](https://qa.library.globalcastmd.com/watch/trauma-ii-solid-organ-injury-1978?t=1222)

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