# Traumatic Brain Injury — GCMD Library living collection

Everything in the library about traumatic brain injury — built automatically from dossiers that name it.

Updated: n/a · 3 episodes · 111 cited statements

## Episodes
### Acute Management
- [Traumatic Brain Injury](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942) — podcast · 14:04 · [machine version](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942.md)

### Case-Based Learning
- [Solid Organ Injury Management: Update Course 2017](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406) — video · 32:57 · [machine version](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406.md)

### In-Depth Reviews
- [Pediatric Trauma With Dr. Richard Falcone](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928) — podcast · 56:05 · [machine version](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928.md)

## Chapters
- [0:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=0) Case Presentation: Multi-System Trauma Initial Assessment (Ep 1)
- [7:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=420) Resuscitation Strategy and Imaging Decisions (Ep 1)
- [15:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=900) ATOMAC Guidelines and Operative Decision-Making (Ep 1)
- [25:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1500) Case Resolution and Key Teaching Points (Ep 1)
- [0:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=0) Introduction and Center Overview (Ep 2)
- [2:54](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=174) Cervical Spine Clearance Protocols (Ep 2)
- [15:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=910) Cervical Spine Clearance in Infants (Ep 2)
- [20:48](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1248) Pancreatic Trauma Management (Ep 2)
- [27:46](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1666) Non-Accidental Trauma Screening (Ep 2)
- [33:09](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1989) Blunt Abdominal Trauma Evaluation (Ep 2)
- [39:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2350) Angioembolization in Pediatric Solid Organ Injury (Ep 2)
- [43:49](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2629) Solid Organ Injury Management Protocols (Ep 2)
- [48:28](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2908) Trauma Activation Criteria (Ep 2)
- [0:11](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=11) Case presentation and initial management (Ep 3)
- [1:58](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=118) Management of intracranial hypertension (Ep 3)
- [6:30](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=390) Role of steroids (Ep 3)
- [7:01](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=421) Surgical options for refractory ICP (Ep 3)
- [8:56](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=536) Imaging strategies: CT versus MRI (Ep 3)
- [10:39](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=639) Management of sympathetic storming (Ep 3)
- [13:16](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=796) Clinical pearls summary (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- A normal shock index is less than 1 or less than 0.9, with adjustments now available for pediatric patients — David (clinical) [Ep 1 · 7:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=420)
- The shock index allows clinicians not regularly seeing pediatric patients to assess for shock without knowing normalized blood pressure values for children — David (clinical) [Ep 1 · 7:30](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=450)
- Massive transfusion protocol must be activated as soon as massive bleeding is recognized, not after reaching a specific threshold, to make a difference in outcome — David (clinical) [Ep 1 · 9:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=540)
- FAST (Focused Assessment with Sonography for Trauma) examines four specific areas: three in the abdomen and one in the pericardial sac, looking only for hemoperitoneum or pericardial effusion, not organ injury — David (clinical) [Ep 1 · 13:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=780)
- FAST remains useful in unstable patients as a replacement for diagnostic peritoneal lavage (DPL) — David (opinion) [Ep 1 · 14:30](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=870)
- The ATOMAC guideline divides patients into stable and unstable categories: stable patients can be transfused to hemoglobin >7 and discharged when bleeding stops; unstable patients who don't respond to packed cells and fluids need operative intervention — David (guideline) [Ep 1 · 20:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1200)
- Young children with head injury are often hypotensive even without active bleeding, while some bleeding children are not hypotensive, making it difficult to define 'stable' vs. 'unstable' — David (clinical) [Ep 1 · 21:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1260)
- Hypotension due to solid organ injury is ominous, with significant risk of death and failure of non-operative management — David (clinical) [Ep 1 · 22:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1320)
- In younger children (not teenagers), blood pressure less than 50 mmHg is a really ominous sign with high risk of poor outcome — David (clinical) [Ep 1 · 22:30](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1350)
- Teenagers and adults can become hypotensive, respond to blood transfusion, and often be managed non-operatively, unlike younger children — David (clinical) [Ep 1 · 23:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1380)
- In patients with traumatic brain injury and shock, resuscitation should be managed based on cerebral perfusion pressure rather than absolute blood pressure when intracranial monitoring is in place — David (clinical) [Ep 1 · 25:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1500)
- The ATOMAC guideline was modified 8 months into the prospective study to specify that recurrent hypotension or lack of sustained response to packed cells constitutes failure of non-operative management, after a patient with multiple injuries died following recurrent hypotension in the PICU — David (guideline) [Ep 1 · 27:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1620)
- The ATOMAC guideline effectively guided care for 1,007 pediatric trauma patients in the prospective validation study — David (epidemiological) [Ep 1 · 28:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1680)
- Only about half of children in shock are hypotensive, meaning shock does not necessarily equal low blood pressure in pediatric patients — David (clinical) [Ep 1 · 28:30](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1710)
- 40 mL/kg (or 4 units of packed cells) remains a validated threshold for failure of non-operative management, supported by both expert opinion and military experience data — David (guideline) [Ep 1 · 32:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1920)
- Blood evacuated from the chest via chest tube may originate from abdominal bleeding through a ruptured diaphragm, making it difficult to determine whether chest tube output should count toward the 40 mL/kg solid organ injury transfusion threshold — David (clinical) [Ep 1 · 32:30](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1950)
- For a patient with small epidural hematoma, immediate neurosurgical consultation is needed to determine if surgical evacuation is required. — Pramod Pulaamba (clinical) [Ep 3 · 1:08](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=68)
- Small epidurals may be managed with repeat CT scan in several hours or clinical observation for deterioration rather than immediate surgery. — Pramod Pulaamba (clinical) [Ep 3 · 1:25](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=85)
- ICP monitoring should be discussed with neurosurgeons for patients being managed for potential intracranial pressure issues. — Pramod Pulaamba (clinical) [Ep 3 · 1:40](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=100)
- Invasive blood pressure monitoring is needed for accurate blood pressure identification in patients with intracranial hypertension. — Pramod Pulaamba (clinical) [Ep 3 · 1:58](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=118)
- Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure. — Pramod Pulaamba (clinical) [Ep 3 · 2:20](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=140)
- Most guidelines suggest keeping cerebral perfusion pressure greater than 45 mmHg as minimal acceptable, sometimes 55 mmHg in children. — Pramod Pulaamba (guideline) [Ep 3 · 2:28](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=148)
- ICP above 20 may require ongoing treatment and/or reevaluation with imaging. — Pramod Pulaamba (clinical) [Ep 3 · 2:42](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=162)
- Acute intracranial hypertension may first manifest as dilation of the ipsilateral pupil or progressive bradycardia with hypertension. — Pramod Pulaamba (clinical) [Ep 3 · 3:00](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=180)
- Acute ICP management includes raising head of bed to improve venous drainage, providing oxygen, and bag valve masking. — Pramod Pulaamba (clinical) [Ep 3 · 3:15](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=195)
- Hyperventilation to PCO2 of around 35 helps vasoconstrict the brain and reduce ICP. — Pramod Pulaamba (clinical) [Ep 3 · 3:35](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=215)
- Opening an ICP drain is one of the first interventions to evacuate fluid and reduce pressure. — Pramod Pulaamba (clinical) [Ep 3 · 3:50](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=230)
- 3% normal saline at 5 mL per kilogram will generally increase serum sodium by 3 to 5 mEq per liter. — Pramod Pulaamba (clinical) [Ep 3 · 4:02](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=242)
- 3% normal saline has a higher osmolarity limit (360 millimoles) compared to Mannitol (320 millimoles). — Pramod Pulaamba (clinical) [Ep 3 · 4:30](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=270)
- Hypotension in the context of closed head injury is a very poor prognosticator and should be avoided at all costs. — Pramod Pulaamba (clinical) [Ep 3 · 4:45](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=285)
- In older children and teenagers, systolic blood pressure should be kept above 90 or 95 mmHg; younger children should use age-appropriate norms. — Pramod Pulaamba (clinical) [Ep 3 · 4:58](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=298)
- Norepinephrine can be used to drive up blood pressure to maintain cerebral perfusion. — Pramod Pulaamba (clinical) [Ep 3 · 5:12](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=312)
- Based on the most recent guidelines published in Pediatric Critical Care Medicine, there is no evidence that 3% saline is better than Mannitol or vice versa. — Pramod Pulaamba (guideline) [Ep 3 · 5:22](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=322)
- Mannitol's diuretic effect can lead to difficult-to-control diuresis and potential hypotension. — Pramod Pulaamba (clinical) [Ep 3 · 5:40](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=340)
- Mannitol's first effect within 15 to 20 minutes is changing blood vessel rheology to allow freer passage through cerebral circulation and improve oxygen delivery, not diuresis. — Pramod Pulaamba (clinical) [Ep 3 · 5:52](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=352)
- The dose of Mannitol is 0.5 to 1 gram per kilogram. — Pramod Pulaamba (clinical) [Ep 3 · 6:13](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=373)
- There is no role for steroids in pediatric traumatic brain injury. — Pramod Pulaamba (guideline) [Ep 3 · 6:33](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=393)
- Steroids are no longer considered effective therapy for suspected spinal cord injury and may cause detriment. — Pramod Pulaamba (guideline) [Ep 3 · 6:42](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=402)
- Neurosurgical options after failed conservative treatment include simple evacuation of surgical lesions like epidurals. — Pramod Pulaamba (clinical) [Ep 3 · 7:01](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=421)
- Decompressive craniectomy is an emerging option for diffuse axonal injury with difficult-to-control ICP when there is no true surgical lesion to decompress. — Pramod Pulaamba (clinical) [Ep 3 · 7:18](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=438)
- For persistently elevated ICP above 20 with higher spikes, the patient will slowly deteriorate to the point of being unsalvageable without intervention. — Pramod Pulaamba (clinical) [Ep 3 · 7:50](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=470)
- In decompressive craniectomy, the bone is preserved and can be replaced after things settle down. — Pramod Pulaamba (clinical) [Ep 3 · 7:40](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=460)
- Based on the third iteration of Management of Traumatic Brain Injury in Children published in Pediatric Critical Care Medicine, there is no clear consensus that decompressive craniectomy improves outcomes. — Pramod Pulaamba (guideline) [Ep 3 · 8:15](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=495)
- Major trauma centers across North America are using decompressive craniectomy more frequently for severe TBI. — Pramod Pulaamba (opinion) [Ep 3 · 8:40](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=520)
- CT scan is preferred in acute situations with acute ICP presentation because it provides the best information for determining need for OR or drain placement. — Pramod Pulaamba (clinical) [Ep 3 · 9:08](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=548)
- MRI is used after the first 48 hours once the patient is stable and ICP spikes are controlled, primarily as a prognosticator. — Pramod Pulaamba (clinical) [Ep 3 · 9:30](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=570)
- MRI is useful in severe cases for counseling families and directing care plans, and can be repeated in a week to determine true extent of injury and level of disability. — Pramod Pulaamba (clinical) [Ep 3 · 9:50](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=590)
- CT head scan can be completed in 5 minutes versus 20-30 minutes for MRI, making it preferable for critical patients. — Pramod Pulaamba (clinical) [Ep 3 · 10:17](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=617)
- Sympathetic storming occurs due to imbalance of sympathetic and parasympathetic nervous systems as a result of head injury. — Pramod Pulaamba (clinical) [Ep 3 · 10:55](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=655)
- Untreated sympathetic storming can lead to secondary brain injury or potentiate ongoing injury. — Pramod Pulaamba (clinical) [Ep 3 · 11:20](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=680)
- Hyperventilation during sympathetic storming leads to vasoconstriction which could cause cerebral hypoxia and further cellular injury. — Pramod Pulaamba (clinical) [Ep 3 · 11:32](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=692)
- Hypertension during sympathetic storming can lead to hemorrhage within the brain. — Pramod Pulaamba (clinical) [Ep 3 · 11:50](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=710)
- Arrhythmias during sympathetic storming can lead to hemodynamic instability and hypoperfusion. — Pramod Pulaamba (clinical) [Ep 3 · 12:02](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=722)
- Neurogenic pulmonary edema is sometimes common in TBI patients and can cause hypoxia and difficult ventilation. — Pramod Pulaamba (clinical) [Ep 3 · 12:15](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=735)
- The cornerstone of sympathetic storming treatment is sedation and pain control, usually with narcotics and/or benzodiazepines as first-line medications. — Pramod Pulaamba (clinical) [Ep 3 · 12:40](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=760)
- Bromocriptine acts on the hypothalamus to reduce hyperthermia, diaphoresis, and blood pressure in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 12:55](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=775)
- Oxycodone has been used for its longer-acting effect for pain control in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Propranolol can help control arrhythmias and lower blood pressure in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Clonidine is an alpha-2 agonist that can reduce levels of catecholamines throughout the body and reduce ongoing sympathetic storm. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 trauma patients per year. — Richard Falcone (clinical) [Ep 2 · 3:08](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=188)
- At Cincinnati Children's Hospital, the ED physician serves as team leader for all trauma activations because they are present when the patient arrives. — Richard Falcone (clinical) [Ep 2 · 3:32](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=212)
- The ultimate risk of C-spine injury in pediatric trauma is actually pretty low. — Richard Falcone (epidemiological) [Ep 2 · 4:32](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=272)
- Approximately 90% of children admitted in C-collars can be clinically cleared the next morning when they are less distracted and not in the trauma bay. — Richard Falcone (clinical) [Ep 2 · 4:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=290)
- Some children are sent home in C-collars with follow-up in trauma clinic in one week where nurse practitioners clear them clinically. — Richard Falcone (clinical) [Ep 2 · 5:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=320)
- Flexion-extension films obtained early when a child is still tender and scared often yield inadequate images. — Richard Falcone (clinical) [Ep 2 · 8:27](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=507)
- Getting CT early in children with normal neurologic exam is not useful because clinicians will not feel comfortable removing the collar based on imaging alone if the child still has tenderness. — Richard Falcone (clinical) [Ep 2 · 9:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=540)
- There is sufficient evidence that awake children without distracting injuries and no midline tenderness do not require X-rays for C-spine clearance. — Richard Falcone (clinical) [Ep 2 · 9:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=590)
- For severe TBI patients, MRI is obtained before C-spine clearance because a normal exam for clinical clearance will not be available within days or even a week. — Richard Falcone (clinical) [Ep 2 · 13:17](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=797)
- Most pediatric centers obtain both CT (for bony abnormalities) and MRI (for soft tissue and ligaments) before clearing the C-spine in obtunded patients, though adult literature suggests CT alone may be sufficient. — Richard Falcone (clinical) [Ep 2 · 13:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=830)
- For severe TBI patients, C-spine CT is not obtained during initial resuscitation but is deferred until the follow-up head CT in the next 24 hours when the patient is more stable. — Richard Falcone (clinical) [Ep 2 · 15:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=910)
- The challenge in pancreatic trauma is determining whether there is a pancreatic duct injury. — Todd Ponsky (clinical) [Ep 2 · 21:35](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1295)
- There is increasing evidence that true pancreatic duct disruption is better treated with early distal pancreatectomy, ideally spleen-preserving. — Todd Ponsky (clinical) [Ep 2 · 21:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1310)
- Some children can have significant-appearing pancreatic injuries on CT, but ERCP or MRCP shows the duct is intact, and these children will heal without surgery. — Todd Ponsky (clinical) [Ep 2 · 22:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1350)
- ERCP has the advantage of being potentially therapeutic (stent placement) but the disadvantage of injecting dye that can cause pancreatic inflammation. — Todd Ponsky (clinical) [Ep 2 · 23:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1390)
- MRCP does not carry the risk of causing pancreatic inflammation that ERCP does. — Todd Ponsky (clinical) [Ep 2 · 23:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1420)
- Conservative management of pancreatic duct disruption can work and pseudocysts are manageable and drainable, but this approach results in longer TPN time and longer hospital length of stay compared to early pancreatectomy. — Todd Ponsky (clinical) [Ep 2 · 24:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1440)
- Centers that report good outcomes with distal pancreatectomy for pancreatic trauma are those with surgeons who are very comfortable operating on the pancreas and do it frequently. — Todd Ponsky (opinion) [Ep 2 · 24:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1480)
- Surgeons who rarely operate on the pancreas may put patients at more complication risk by attempting distal pancreatectomy, and non-operative management may be in the patient's best interest at such centers. — Todd Ponsky (opinion) [Ep 2 · 25:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1510)
- Being indecisive about pancreatic trauma management and operating around day 3 leads to worse outcomes than either early surgery or committed non-operative management. — Richard Falcone (opinion) [Ep 2 · 25:33](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1533)
- More literature is trending toward operating on pancreatic duct injuries more frequently, and if surgery is chosen, it should be done within the first 24 hours. — Todd Ponsky (clinical) [Ep 2 · 26:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1570)
- The decision to operate on pancreatic trauma should be made within the 24-hour window after obtaining ERCP or MRCP to confirm duct disruption. — Todd Ponsky (clinical) [Ep 2 · 26:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1610)
- If intraoperative findings show parenchymal pancreatic injury without ductal disruption, the appropriate management is drainage rather than distal pancreatectomy. — Todd Ponsky (clinical) [Ep 2 · 27:28](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1648)
- Cincinnati Children's Hospital data showed that before implementing standardized screening, low socioeconomic status and minority children with head injuries were much more likely to receive skeletal surveys and social services evaluation than middle/upper class non-minority families. — Todd Ponsky (epidemiological) [Ep 2 · 28:04](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1684)
- Abuse occurs in all races and all socioeconomic groups, though economic stress may add some risk. — Todd Ponsky (epidemiological) [Ep 2 · 29:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1750)
- Cincinnati Children's Hospital implemented a protocol where all children under 2 admitted with head injuries from mechanisms not witnessed publicly receive skeletal survey and social work evaluation. — Todd Ponsky (clinical) [Ep 2 · 29:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1780)
- Publicly witnessed mechanisms are defined as events seen by unrelated parties (e.g., fall from grocery cart at supermarket, motor vehicle collision), not events witnessed only by family members or caregivers. — Todd Ponsky (clinical) [Ep 2 · 30:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1830)
- After implementing standardized screening criteria, the percentage of positive abuse cases remained at 50% despite evaluating more children, indicating previously undetected abuse was being identified. — Todd Ponsky (epidemiological) [Ep 2 · 31:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1870)
- The 50% positive abuse rate in screened children represents a biased population because they had injuries severe enough to require hospital admission. — Todd Ponsky (epidemiological) [Ep 2 · 31:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1900)
- A screening test with nearly 50% positive rate is more productive than most screening tests used for other conditions. — Todd Ponsky (opinion) [Ep 2 · 32:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1930)
- Families find standardized non-accidental trauma screening more reassuring because it can be explained as standard protocol for all families with this injury type, not a judgment about the specific family. — Todd Ponsky (clinical) [Ep 2 · 32:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1960)
- Ophthalmologic examination is not part of routine non-accidental trauma screening at Cincinnati Children's Hospital but is obtained if skeletal survey is positive or there are other concerning findings. — Richard Falcone (clinical) [Ep 2 · 33:23](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2003)
- Abnormal liver function tests greater than 150-200 indicate good chance of some abdominal injury, but normal LFTs provide very little evidence of safety. — Todd Ponsky (clinical) [Ep 2 · 37:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2220)
- Cincinnati Children's Hospital has moved away from routine LFTs, amylase, and lipase in trauma patients, obtaining them only when other indications for CT scan already exist. — Todd Ponsky (clinical) [Ep 2 · 37:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2260)
- FAST examination has low sensitivity and is very user-dependent, providing false sense of security in stable patients. — Todd Ponsky (clinical) [Ep 2 · 38:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2290)
- FAST remains useful for hypotensive patients to rapidly determine if there is blood in the abdomen, which was the original indication for its development. — Todd Ponsky (clinical) [Ep 2 · 38:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2320)
- Laboratory tests may be useful as one additional screening test for children with vague symptoms and mechanisms who are being considered for discharge, with positive labs prompting CT and negative labs supporting discharge. — Richard Falcone (opinion) [Ep 2 · 41:26](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2486)
- Cincinnati Children's Hospital has not used angioembolization for solid organ injury in approximately 4-5 years despite high trauma volume. — Richard Falcone (clinical) [Ep 2 · 41:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2510)
- Angioembolization is used more frequently at adult trauma centers that routinely perform the procedure for adult patients. — Richard Falcone (clinical) [Ep 2 · 42:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2540)
- CT blush on imaging puts patients at higher risk for needing intervention or transfusion but does not mandate intervention. — Richard Falcone (clinical) [Ep 2 · 42:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2570)
- In small children, angioembolization may put them at more risk of injury and may eliminate most of the spleen anyway, losing the benefit of splenic preservation. — Richard Falcone (clinical) [Ep 2 · 43:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2600)
- Pediatric surgeons' approach to solid organ injury management was subsequently adopted by adult trauma surgeons. — Richard Falcone (clinical) [Ep 2 · 44:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2680)
- Children with solid organ injuries can be mobilized much more quickly than originally recommended, without the slow progression from bed to bathroom to ambulation. — Richard Falcone (clinical) [Ep 2 · 46:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2770)
- Very few grade 1 solid organ injuries require transfusion, so routine serial lab draws as outlined in original Stylianos protocol are probably unnecessary. — Richard Falcone (clinical) [Ep 2 · 46:38](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2798)
- There is growing support for less frequent lab draws and shorter length of stay for pediatric solid organ injuries. — Richard Falcone (clinical) [Ep 2 · 47:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2870)
- Isolated grade 1 splenic injuries may not require hospital admission because they never require transfusion and never have problems. — Richard Falcone (clinical) [Ep 2 · 48:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2890)
- Cincinnati Children's Hospital protocol for grade 1 solid organ injuries includes one 12-hour lab check only. — Richard Falcone (clinical) [Ep 2 · 48:28](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2908)
- Grade 2 solid organ injuries receive two lab checks, and grade 3 injuries may receive two or three checks based on clinical exam. — Richard Falcone (clinical) [Ep 2 · 48:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2930)
- There is evidence supporting tiered trauma activation systems with different levels of team response. — Richard Falcone (clinical) [Ep 2 · 49:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2960)
- Cincinnati Children's Hospital uses a 3-level activation system: lowest level is ED only with surgery called if needed, mid-level includes ED and surgery resident, highest level includes attending surgeon, OR staff, anesthesia, and ICU. — Richard Falcone (clinical) [Ep 2 · 49:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2990)
- Centers often add multiple additional activation criteria based on individual cases, resulting in 10-20 criteria that cause confusion. — Richard Falcone (clinical) [Ep 2 · 51:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3070)
- The optimal number of activation criteria is around 8-9, as more criteria lower under-triage but significantly increase over-triage. — Richard Falcone (clinical) [Ep 2 · 54:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3240)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- FAST has lost appeal in stable pediatric trauma patients because it misses too many injuries, as shown by the PECARN Group study — David summarizing the discussion [Ep 1 · 14:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=840)
- Adult studies show that ideal blood pressure after head injury is much higher than previously thought, with blood pressure of 150-160 mmHg associated with better outcomes than 90-120 mmHg, suggesting Cushing's reflex may be protective — David summarizing the discussion [Ep 1 · 24:00](https://qa.library.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1440)
- Traumatic brain injury caused over 837,000 visits, hospitalizations, and deaths in children in 2014. — Em Gootee summarizing a resource [Ep 3 · 0:11](https://qa.library.globalcastmd.com/watch/traumatic-brain-injury-1942?t=11)
- The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations in the Journal of Trauma 2-3 years ago emphasizing clinical examination as the first test. — Richard Falcone summarizing a resource [Ep 2 · 6:04](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=364)
- For children greater than 8 years old with normal X-rays and normal neurologic exam, re-examination allows clinical clearance without CT if the repeat exam is normal. — Richard Falcone summarizing a resource [Ep 2 · 7:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=420)
- CT or MRI of the C-spine should be considered only when there is an abnormal neurologic exam, requiring involvement of spine surgeons. — Richard Falcone summarizing a resource [Ep 2 · 7:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=450)
- A multi-site study published in Journal of Trauma around 2009 developed a scoring system for C-spine injury risk in children under 3: 3 points for GCS <14, 2 points for GCS injury score of 1, 2 points for motor vehicle collision, 1 point for age 2-3 years. — Richard Falcone summarizing a resource [Ep 2 · 16:07](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=967)
- Children under 3 with a C-spine risk score of 0 or 1 have 0.0% chance of C-spine injury and do not need imaging. — Richard Falcone summarizing a resource [Ep 2 · 17:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1030)
- Children under 3 with a C-spine risk score of 7 or 8 have approximately 21% chance of C-spine injury and clearly need imaging. — Richard Falcone summarizing a resource [Ep 2 · 17:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1060)
- In the multi-site study, pediatric Level 1 centers obtained C-spine CTs only 17% of the time compared to adult centers which obtained them 24-45% of the time. — Richard Falcone summarizing a resource [Ep 2 · 18:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1090)
- The Pediatric Emergency Care Research Network published criteria in Annals of Emergency Medicine in 2013 for identifying children at very low risk of clinically important blunt abdominal injuries. — Todd Ponsky summarizes what Dr. Richard Falcone said [Ep 2 · 34:29](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2069)
- Children with no abdominal wall trauma, no seatbelt sign, GCS 14-15, no abdominal tenderness, no thoracic wall trauma, no abdominal pain, no altered breath sounds, and no vomiting have 0.1% chance of clinically important intraabdominal injury and do not need CT scanning. — Todd Ponsky summarizes what Dr. Richard Falcone said [Ep 2 · 35:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2120)
- If the PECARN criteria were strictly followed to scan everyone not in the very low risk group, more CTs would be recommended than pediatric trauma centers currently perform. — Todd Ponsky summarizes what Dr. Richard Falcone said [Ep 2 · 36:24](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2184)
- Children with abdominal wall trauma (seatbelt sign, handlebar sign) or GCS less than 14 have approximately 5% chance of abdominal injury requiring intervention. — Richard Falcone summarizing a resource [Ep 2 · 39:39](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2379)
- Children with only abdominal tenderness (without wall trauma or altered GCS) have approximately 1.4% risk of intraabdominal injury needing intervention. — Richard Falcone summarizing a resource [Ep 2 · 40:20](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2420)
- Children with only thoracic wall trauma, vague abdominal pain, or vomiting have only 0.7% risk of intraabdominal injury. — Richard Falcone summarizing a resource [Ep 2 · 40:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2450)
- Dr. Stylianos published landmark paper in 1999 with the American Pediatric Surgical Association Trauma Committee that changed management of splenic and liver trauma in children. — Richard Falcone summarizing a resource [Ep 2 · 44:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2640)
- Sean St. Peter and the Kansas City group published papers showing that bed rest windows for solid organ injuries can be shortened: grade 1-2 injuries need at most overnight (12 hours), grade 3-4 injuries need about two nights. — Richard Falcone summarizing a resource [Ep 2 · 45:00](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2700)
- Shortened bed rest protocols significantly reduce length of stay without causing readmissions or complications. — Richard Falcone summarizing a resource [Ep 2 · 45:50](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2750)
- Dennis Bensard's group from Colorado presented at Western Trauma Association proposing no lab draws at all for solid organ injuries if patients are clinically stable (not tachycardic, no pain, no vital sign changes). — Richard Falcone summarizing a resource [Ep 2 · 47:10](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2830)
- The American College of Surgeons specifies 6 required trauma activation criteria but these are generic, adult-based, and lack strong evidence. — Richard Falcone summarizing a resource [Ep 2 · 50:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3040)
- A multi-center prospective study published in 2012 matched activation criteria to resources used (intubation, blood transfusion within 30 minutes, chest tube within 30 minutes, CPR within 30 minutes, OR within 60 minutes). — Richard Falcone summarizing a resource [Ep 2 · 51:40](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3100)
- The resource-based study identified optimal activation criteria as: penetrating wound to head/neck/torso, age-appropriate tachycardia or poor perfusion, receiving blood prior to arrival, systolic BP <90 or age-appropriate hypotension, 40+ mL/kg fluid prior to arrival, respiratory distress/failure, or GCS ≤8. — Richard Falcone summarizing a resource [Ep 2 · 52:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3150)
- Using the resource-based criteria resulted in 39% over-triage rate and only 10% under-triage rate. — Richard Falcone summarizing a resource [Ep 2 · 53:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3210)
- Brooke Lerner led a recent Journal of Trauma paper using Delphi method to formally define high-resource utilization justifying highest-level activation, including ICU stay >48 hours. — Richard Falcone summarizing a resource [Ep 2 · 54:30](https://qa.library.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3270)

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