Rich Falcone

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I mean, I'm most scared when you have a kid this age that's not crying, right? I mean, a kid that doesn't respond to their IV stick or their IO is, or a kid that's crying a lot and then suddenly stops crying, that's who I'm most worried about in the trauma bay from a neurostatus.

quote · Early Assessment and Management of Trauma

FAST is great if you have a hypotensive patient. Um, that you're really looking for the, the, as I'd say, the classic reason that FAS was developed, the hypotensive patient you're trying to prove, do they have a bunch of blood in their, in their abdomen or not.

quote · Cervical Spine Injury

Their mediastinum is more mobile, so it'll, it'll shift more easily in response to that tension, whereas you get a little older. And then it takes a lot more pressure to kind of move the trachea, you know, put pressure on the, the cava and things like that.

quote · Early Assessment and Management of Trauma

There's data that's a conservative management can work even if there is a duct disruption. They may get a pseudocyst, but those are manageable and drainable. But there's also data that says that takes longer, more TPN time, more hospital length of stay.

quote · Cervical Spine Injury

I mean we're also fortunate here that we have amazing ENT folks, so you save the kid's life, but you give them a little tracheal ring damage and Subglottic stenosis, well, that's a lot better choice than being dead because you didn't do something.

quote · Hemorrhagic Shock

They got big tongues. Their heads are big too. You lay them on their backboard and that already starts flexing their head forward, um, because they're big oxfoot which starts to, in obstruct. Their airway as well.

quote · Hemorrhagic Shock

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Rich's statements about Cervical Spine Injury 30 statements

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Trauma

Statement Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 trauma patients annually. Open

Statement At Cincinnati Children's, the emergency department physician serves as team leader for all traumas, chosen because they are present when every patient arrives. Open

Quotation I think there's a couple things that that we've learned. One is the, the ultimate risk of injury is actually pretty low, um, and C-spine, a C collar is often a useful adjunct, um, uh, that gives you time. Open

Statement The ultimate risk of C-spine injury in pediatric trauma is actually pretty low. Open

Statement At Cincinnati, 90% of children left in C-collars overnight can be clinically cleared the next morning when less distracted and not in the trauma bay. Open

Statement Getting CT early in kids with normal neurologic exam and C-spine tenderness is not useful because clinicians won't feel comfortable removing the collar based on imaging alone without resolution of clinical tenderness. Open

Statement There is enough evidence now that truly awake children without distracting injuries and no midline tenderness do not need X-rays for C-spine clearance. Open

Quotation I think the bottom line is trust your clinical exam, and I think we've, you know, across all pediatric surgery, probably in all adult surgery, have gone away from trusting your clinical exam and falling to imaging. Open

Statement For obtunded patients with severe TBI, Cincinnati's protocol is CT to rule out bony abnormalities followed by MRI if CT is clear, before removing the C-collar. Open

Quotation I think the challenge in pancreas trauma is really trying to figure out is there a duct, a duct injury or not. I think that's, that's your number one, your number one question and your number one concern. Open

Statement The primary challenge in pancreatic trauma is determining whether there is a pancreatic duct injury, which is the number one concern. Open

Statement CT scans can show significant pancreatic injuries with large cracks through the neck, but ERCP or MRCP may still show the duct is intact, and those children will heal without surgery. Open

Statement ERCP has the advantage of being potentially therapeutic with stent placement but the disadvantage of injecting dye that can cause pancreatic inflammation, a risk not present with MRCP. Open

Quotation There's data that's a conservative management can work even if there is a duct disruption. They may get a pseudocyst, but those are manageable and drainable. But there's also data that says that takes longer, more TPN time, more hospital length of stay. Open

Statement Centers that perform frequent pancreatic operations and are comfortable with laparoscopic distal pancreatectomy have better outcomes operating on pancreatic trauma; centers that rarely operate on the pancreas may put patients at more complication risk and should consider non-operative management. Open

Statement Cincinnati implemented standardized screening where all children under 2 admitted with head injuries from non-publicly-witnessed mechanisms receive skeletal surveys and social work evaluation, eliminating clinician bias in screening decisions. Open

Quotation One of the things that that we struggled with is who's making that decision to that which kid needs to be screened and it and how much bias, how much bias there exists around that decision. Open

Statement Before implementing standardized screening, Cincinnati was more likely to perform skeletal surveys on low SES or minority children with head injuries than on middle/upper class non-minority families with identical injuries. Open

Quotation Despite evaluating more kids, we would, you would have expected if you increased your denominator, um, you know, your percent positives, you know, positive abuse rates are going to drop. We actually didn't see that. We saw it stayed exactly the same. Open

Statement After implementing unbiased standardized screening criteria, Cincinnati's positive abuse rate remained at 50% despite evaluating more children, indicating they were finding abused children who would not have been screened under the previous biased system. Open

Statement A screening test with nearly 50% positive rate for abuse in admitted children under 2 with head injuries is more productive than most screening tests used for other conditions. Open

Statement Families find standardized screening more reassuring because clinicians can explain it is done for every family with this injury type without making judgments about truthfulness. Open

Quotation Families find it. More reassuring now with our new system, and it's easier, quite honestly, for us to be able to say we do this for every family with this type of injury. We're not making any judgment about you. We're not making any judgment about whether you're telling us the truth or not. Open

Statement Cincinnati does not routinely perform ophthalmologic exams for non-accidental trauma screening, only obtaining them if skeletal survey is positive or there are other concerning findings like bruising or abnormal head findings inconsistent with the given story. Open

Statement Cincinnati has gone away from getting LFTs, amylase, and lipase as routine in trauma patients, only obtaining them if there are other indications for CT scan such as abdominal bruising or tenderness. Open

Quotation Normal labs don't prove that you don't have an. Injury, they just make us feel better. Open

Quotation FAST is great if you have a hypotensive patient. Um, that you're really looking for the, the, as I'd say, the classic reason that FAS was developed, the hypotensive patient you're trying to prove, do they have a bunch of blood in their, in their abdomen or not. Open

Statement Cincinnati has not used angioembolization for solid organ injury in the last 4-5 years despite their high trauma volume. Open

Statement Cincinnati's current protocol for solid organ injuries: grade 1 gets one 12-hour lab check, grade 2 gets two checks, grade 3 may get two or three checks based on clinical exam. Open

Quotation We found that doing this we would have had a under over triage rate of 39% and an under triage of of only 10 10%. Open

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ATLS 2021 Pediatric Surgery Update

Statement The priorities when evaluating a small child with multi-system trauma are the same as for an adult patient: airway, breathing, circulation (ABCs). Open

Quotation Don't get hyper, you know, acute that, well, this is a 3 year old and not a 30-year-old, you know, drunk guy who was in an a car accident. Your, your priorities are going to be, it's going. be the same. Open

Quotation They're more pliable chests, right? So the, the ribs don't necessarily break, but what do you have to worry about then? Well, they can have a lot of pulmonary contusions and, and other injuries. Open

Statement Pediatric patients have more pliable chests so ribs don't necessarily break, but they can have a lot of pulmonary contusions and other injuries. Open

Statement Pediatric patients have a more mobile mediastinum that will shift more easily in response to tension pneumothorax compared to older patients. Open

Quotation Their mediastinum is more mobile, so it'll, it'll shift more easily in response to that tension, whereas you get a little older. And then it takes a lot more pressure to kind of move the trachea, you know, put pressure on the, the cava and things like that. Open

Statement 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. Open

Statement 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. Open

Quotation I love that rule, ear in line with the shoulder because little kids like this, they just got big heads. Open

Quotation They got big tongues. Their heads are big too. You lay them on their backboard and that already starts flexing their head forward, um, because they're big oxfoot which starts to, in obstruct. Their airway as well. Open

Statement Airway management should follow a stepwise approach starting with simple maneuvers like jaw thrust before progressing to more invasive interventions. Open

Quotation Needle crike and the, the small airway, um, usually say under 10, um, would be for the needle versus over 10 before. Surgical Craig, that's what ATLS will tell you. Open

Statement ATLS guidelines recommend needle cricothyroidotomy for patients under 10 years old and surgical cricothyroidotomy for patients over 10. Open

Quotation You save the kid's life, but you give them a little, you know, tracheal ring damage and Subglottic stenosis, well, that's a lot better choice than being dead because you didn't do something. Open

Statement Provider comfort level matters in cricothyroidotomy choice; saving a life with potential tracheal damage is better than death from inaction. Open

Quotation Shock is going to be seen in a 15 kg kid after you lose. One can of Coca-Cola. Open

Statement Pediatric blood volume can be calculated as weight in kilograms times 80 mL. Open

Statement A 12 kg child's entire blood volume is approximately one liter; a 25 kg child has approximately 2 liters. Open

Quotation Weight in kilos times 80 mLs is the blood volume, right? So let's do some math here. A 12 kg kid's entire blood volume is gonna be about a liter. Open

Statement 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. Open

Statement Glasgow Coma Scale can be assessed in nonverbal children; they should not automatically receive a low verbal score just because they cannot talk. Open

Quotation I mean, I'm most scared when you have a kid this age that's not crying, right? I mean, a kid that doesn't respond to their IV stick or their IO is, or a kid that's crying a lot and then suddenly stops crying, that's who I'm most worried about in the trauma bay from a neurostatus. Open

Quotation Don't forget that you can do it. GCS in a child that's nonverbal, right? It's they don't, they don't automatically get a 0 or a 1 for verbal just because they can't talk, right? Open

Statement 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. Open

Quotation Kids are more at risk because of big heads, soft skulls, and they often fall on their head. Open

Statement Children have more diffuse brain injuries in general than adults. Open

Statement Child abuse is the most common cause of severe head injury in children less than 2 years old. Open

Statement Children are more at risk for head injury because of big heads, soft skulls, and tendency to fall on their heads. Open

Quotation Kids have more diffuse brain injuries in general than your adult population. Open

Quotation Child abuse said. is the most common cause of severe head injury in kids less than, less than 2. Open

Rich's statements about Hemorrhagic Shock 57 statements

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