Richard Falcone

84 statements · 3 topics · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · guest expert

Featured statements

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.

opinion · Cervical Spine Injury

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.

clinical · Cervical Spine Injury

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.

clinical · Traumatic Brain Injury

Adult trauma centers need to achieve equivalent imaging rates and lengths of stay to pediatric trauma centers for adolescents, since 51% of these patients go to adult hospitals.

opinion · Trauma

Being indecisive about pancreatic trauma management and operating around day 3 leads to worse outcomes than either early surgery or committed non-operative management.

opinion · Traumatic Brain Injury

More patients were discharged to home rather than to rehab or skilled nursing facilities when cared for at pediatric trauma centers compared to adult trauma centers.

epidemiological · Trauma

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Richard's statements about Cervical Spine Injury 33 statements

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Pediatric Trauma With Dr. Richard Falcone

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

Statement At Cincinnati Children's Hospital, the ED physician serves as team leader for all trauma activations because they are present when the 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 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. Open

Statement Some children are sent home in C-collars with follow-up in trauma clinic in one week where nurse practitioners clear them clinically. Open

Statement Flexion-extension films obtained early when a child is still tender and scared often yield inadequate images. Open

Statement 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. Open

Statement There is sufficient evidence that awake children without distracting injuries and no midline tenderness do not require 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 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. Open

Statement 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. Open

Statement 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. Open

Statement Being indecisive about pancreatic trauma management and operating around day 3 leads to worse outcomes than either early surgery or committed non-operative management. Open

Quotation I think you either operate or you don't, but going in that middle ground was when I found myself in trouble. Open

Statement 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. Open

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

Statement 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. Open

Statement Cincinnati Children's Hospital has not used angioembolization for solid organ injury in approximately 4-5 years despite high trauma volume. Open

Statement Angioembolization is used more frequently at adult trauma centers that routinely perform the procedure for adult patients. Open

Statement CT blush on imaging puts patients at higher risk for needing intervention or transfusion but does not mandate intervention. Open

Statement 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. Open

Statement Pediatric surgeons' approach to solid organ injury management was subsequently adopted by adult trauma surgeons. Open

Statement Children with solid organ injuries can be mobilized much more quickly than originally recommended, without the slow progression from bed to bathroom to ambulation. Open

Statement Very few grade 1 solid organ injuries require transfusion, so routine serial lab draws as outlined in original Stylianos protocol are probably unnecessary. Open

Statement There is growing support for less frequent lab draws and shorter length of stay for pediatric solid organ injuries. Open

Statement Isolated grade 1 splenic injuries may not require hospital admission because they never require transfusion and never have problems. Open

Statement Cincinnati Children's Hospital protocol for grade 1 solid organ injuries includes one 12-hour lab check only. Open

Statement Grade 2 solid organ injuries receive two lab checks, and grade 3 injuries may receive two or three checks based on clinical exam. Open

Statement There is evidence supporting tiered trauma activation systems with different levels of team response. Open

Statement 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. Open

Statement Centers often add multiple additional activation criteria based on individual cases, resulting in 10-20 criteria that cause confusion. Open

Statement The optimal number of activation criteria is around 8-9, as more criteria lower under-triage but significantly increase over-triage. Open

Richard's statements about Trauma 18 statements

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Differences Between Pediatric & Adult Trauma Centers

Quotation Hi everyone, I'm Rich Falcone, I'm professor of pediatric surgery at Cincinnati Children's Open

Statement There is substantial data showing pediatric trauma centers are better for young children, but evidence for the 15-19 year old age group is less clear. Open

Statement A previous study looking at Ohio alone showed no difference in outcomes for 15-19 year olds whether treated at adult or pediatric trauma centers. Open

Statement The Walther et al. study used the National Trauma Data Bank and included patients aged 15-19 with injury severity scores greater than 25 over a 5-year period. Open

Statement The study identified almost 13,000 patients meeting the inclusion criteria, with 51% treated at adult trauma centers and 49% at pediatric trauma centers. Open

Statement The patient groups at adult and pediatric trauma centers were demographically very similar without significant differences. Open

Statement The median injury severity score was 33 and 45% of patients had Glasgow Coma Scale scores less than 8, indicating severe brain injuries. Open

Statement There was no significant difference in mortality outcomes between adolescents treated at adult versus pediatric trauma centers. Open

Statement Patients at pediatric trauma centers had shorter length of stay and shorter ICU length of stay compared to those at adult trauma centers. Open

Statement More patients were discharged to home rather than to rehab or skilled nursing facilities when cared for at pediatric trauma centers compared to adult trauma centers. Open

Statement Mortality is not the most important or reliable outcome for pediatric trauma because most children survive once they reach a hospital. Open

Statement The study adds evidence that pediatric trauma centers add value for children even into the adolescent age range. Open

Statement Adult trauma centers need to achieve equivalent imaging rates and lengths of stay to pediatric trauma centers for adolescents, since 51% of these patients go to adult hospitals. Open

Statement Adolescents treated at adult trauma centers were approximately 81% more likely to have an imaging study performed compared to those at pediatric trauma centers. Open

Quotation Mortality again in this study, like the isolated Ohio study, there was no difference, but as we know, looking at mortality for pediatric trauma is not the most important or not a reliable outcome since fortunately once they reach a hospital, most kids survive. Open

Quotation You can trust your clinical diagnosis. You can trust your clinical exam and evaluating these kids, and they don't need that radiation exposure. Open

Statement Pediatric trauma centers can achieve the same outcomes with less imaging by trusting clinical diagnosis and clinical examination. Open

Statement Less imaging with same outcomes and shorter length of stay proves that severely injured adolescents can be managed without unnecessary radiation exposure. Open

Richard's statements about Traumatic Brain Injury 33 statements

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