David Notrica

32 statements · 1 topic · summaries given as host listed separately

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the better criteria for whether or not a patient is bleeding is not serial hemoglobins, it's physical examination and vital signs

quote · Hemorrhagic Shock

half the patients who fail non-operative management do it because they develop peritonitis, not because they continue to bleed

quote · Hemorrhagic Shock

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David's statements about Hemorrhagic Shock 32 statements

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Trauma II: Solid Organ Injury

Quotation Atomic started around 2010, and it's interesting because when we decided that we were going to do an algorithm for how to treat solid organ injury, we were really inspired by all of the research that had been done up until that point. Open

Statement 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 Open

Quotation pediatric surgeons have always said let's look at the patient. Let's, let's make the decisions based on our physical examination skills and CT scans are important, but man, looking at the patients still important, even in 2018. Open

Statement Hypotension is a late finding in pediatric hemorrhagic shock; almost half of patients requiring early transfusion are not hypotensive Open

Quotation hypotension is late finding, that by the time kids are hypotensive, it's very, very late Open

Quotation when a patient arrives to you and they are hypovolemic, a pediatric patient arrives to you hypovolemic, the only thing that you know is that they have bled. You don't really know if they're still bleeding. Open

Statement 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 Open

Quotation kids have an amazing ability to stop bleeding and far superior to adult patients Open

Statement 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 Open

Quotation they're not bleeding crystalloid Open

Statement After 20 mL/kg of crystalloid, blood transfusion should be initiated if non-operative management is desired and good outcomes are the goal Open

Quotation if you give this stuff early and don't give them a ton of crystalloid, they don't even go into that DIC and need that massive transfusion. That's actually where you want to be. Open

Statement 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 Open

Statement Many patients with contrast extravasation on CT will stop bleeding spontaneously without angioembolization Open

Statement 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 Open

Statement 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 Open

Quotation Children are absolutely amazing, and all of the things that we have to do to keep adult patients alive. May not benefit children. Open

Statement 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 Open

Statement In renal injury, bed rest makes no difference in outcomes whether patients are walking or on strict bed rest Open

Quotation I don't think bed rest does anything Open

Statement 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 Open

Statement 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 Open

Quotation the better criteria for whether or not a patient is bleeding is not serial hemoglobins, it's physical examination and vital signs Open

Statement Half of patients who fail non-operative management do so because they develop peritonitis, not because of continued bleeding Open

Quotation half the patients who fail non-operative management do it because they develop peritonitis, not because they continue to bleed Open

Statement 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 Open

Statement 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 Open

Quotation the patients who needed additional imaging or who needed additional therapy all presented back to the emergency room. With pain or problems, and the ones that came to the office didn't provide much benefit to the patient. Open

Statement 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) Open

Statement 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 Open

Statement 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 Open

Statement 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 Open

Summaries David gave as host · 7 summaries

Recaps of other experts' statements, not David's own clinical position.

Summaries David gave as host · Hemorrhagic Shock 7 summaries

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Trauma II: Solid Organ Injury

Host summary David Notrica summarizing a resource: 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 Open

Host summary David Notrica summarizing a resource: the original decision to manage patients based on grade of injury rather than hemodynamic status was kind of a consensus opinion or an expert opinion Open

Host summary David Notrica summarizing a resource: 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 Open

Host summary David Notrica summarizing a resource: John Holcomb's work showed that early blood transfusion reduces the number of patients progressing to massive transfusion protocol requirements Open

Host summary David Notrica summarizing a resource: I ran into Steve Stiglianos and I said, you know, I think we're requiring too much bed rest for these kids. He says, We never included bed rest in this. Open

Host summary David Notrica summarizing a resource: Bed rest was never included in the original APSA protocols for solid organ injury management, though it became culturally embedded in practice without evidence Open

Host summary David Notrica summarizing a resource: 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 Open