Discharge instructions should list symptoms that indicate complications: abdominal pain, respiratory problems (for splenic injury), and jaundice. All direct patients back to the emergency room except jaundice, which warrants a phone call to the office for triage since it may represent hematoma mobilization rather than bile leak.
quoteAtomic 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.↗
▶Ep 2 · 2:11
clinicalATOMIC (A Trauma Outcomes and Management Investigation Consortium) began around 2010 as a multi-center prospective study to develop evidence-based algorithms for solid organ injury management, starting with 5 hospitals and expanding to 10.↗
▶Ep 2 · 4:27
clinicalEarly research by Sam Smith and colleagues in Arkansas demonstrated that patients with solid organ injury could be managed based on hemodynamic status rather than CT grade of injury, published in papers including 'Throwing Out the Grade Book.'↗
▶Ep 2 · 6:36
clinicalHypotension is a late finding in pediatric hemorrhagic shock; almost half of patients requiring early transfusion are not hypotensive.↗
▶Ep 2 · 7:47
clinicalWhen a hypovolemic pediatric patient arrives, you only know they have bled; you often don't know if they're still bleeding until you give them blood and they prove ongoing bleeding. Children have superior ability to stop bleeding compared to adults.↗
▶Ep 2 · 7:47
clinicalThe terminology 'stable' and 'unstable' was abandoned in favor of 'bleeding or having bled recently' because defining hemodynamic stability in children is problematic: concurrent head injuries may prevent tachycardia, some unstable patients are not hypotensive, and tachycardia may be due to pain rather than bleeding.↗
▶Ep 2 · 8:38
clinicalShock 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. An elevated shock index misses very few patients in hypovolemic shock; if shock index is not elevated, the patient is probably not actively bleeding.↗
▶Ep 2 · 10:31
guidelineAfter 20 mL/kg of crystalloid, blood transfusion should be initiated if non-operative management is desired and good outcomes are the goal. This contrasts with older ATLS guidelines recommending 60 mL/kg crystalloid before blood.↗
opinionTEG (thromboelastography) and ROTEM (rotational thromboelastometry) directed component therapy makes theoretical sense and is used at Phoenix Children's Hospital, but definitive evidence comparing directed therapy to 1:1:1 ratios in children requires a randomized controlled trial.↗
▶Ep 2 · 16:08
clinicalAngioembolization is safe in pediatric blunt liver and spleen injury. For splenic injury, no patients who underwent embolization went on to fail non-operative management.↗
▶Ep 2 · 16:08
clinicalMany patients with hepatic injury who underwent angioembolization still required laparoscopy or washout, often converted from active bleeding to managing bile complications or intra-abdominal blood.↗
▶Ep 2 · 16:08
clinicalMany patients with contrast extravasation on CT will stop bleeding spontaneously without angioembolization. Angioembolization criteria should be similar to failure of non-operative management: persistent bleeding requiring ongoing blood transfusion.↗
▶Ep 2 · 18:23
guidelineFor ICU admission: grade 1-4 injuries can be managed on the floor if hemodynamically stable or not actively bleeding. Grade 5 injuries should go to the ICU based on injury grade alone, though this represents a small subset of patients.↗
▶Ep 2 · 20:22
clinicalBed rest was never included in the original APSA protocols (per Steve Stiglianos) but became part of the culture. There is no literature supporting bed rest for solid organ injury.↗
▶Ep 2 · 20:22
clinicalOne adult study comparing bed rest versus no bed rest found no increased incidence of bleeding without bed rest. For renal injury, bed rest makes no difference whether patients walk to the bathroom or remain on strict bed rest.↗
▶Ep 2 · 20:22
clinicalThe threshold for failure of non-operative management is 40 mL/kg of all blood products, based on data from NEF and military experience showing patients transfused more than 40 mL/kg are more likely to need operation and more likely to die.↗
▶Ep 2 · 20:22
quoteI 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. I'm like, Really? And it turns out bed rest wasn't really part of the initial requirement even on the AFSA protocols, but it became a very important part of the culture of what we did for the kids.↗
▶Ep 2 · 21:00
quoteYou're absolutely right, they were not resting in bed. They were jumping on the bed.↗
▶Ep 2 · 21:30
quoteI don't think that taking an injured organ and walking it to the bathroom is going to suddenly cause it to bleed.↗
▶Ep 2 · 22:00
clinicalPatients with blunt liver or spleen injury showing no signs of bleeding, no hemodynamic instability, and no hematocrit drop do not need a minimum hospitalization time. An 18-hour observation period is sufficient; if they haven't bled in 18 hours, they are very unlikely to bleed. This is supported by data showing all transfused patients and all failures occurred early.↗
▶Ep 2 · 22:00
clinicalSerial hemoglobins are not necessary in stable patients. Hemoglobin drops for multiple reasons unrelated to bleeding: lab error, drawing upstream from IV, dilution from excess fluid. Physical examination and vital signs (especially rising heart rate, poor capillary refill, pallor, cold extremities) are better indicators of ongoing bleeding and will identify every patient needing transfusion or failing non-operative management.↗
▶Ep 2 · 24:03
clinicalHalf of patients who fail non-operative management do so because they develop peritonitis, not because of continued bleeding.↗
▶Ep 2 · 24:41
clinicalFollow-up visits for higher-grade injuries have not provided much benefit to patients. Patients with complications presented to the emergency room with symptoms; the follow-up visit itself did not identify problems or change management.↗
▶Ep 2 · 24:41
clinicalMany patients with low-grade injuries never showed for follow-up clinic appointments. Telephone follow-up was implemented for low-grade injuries to confirm patient status without requiring additional missed school days.↗
▶Ep 2 · 25:40
guidelineDischarge instructions should list symptoms that indicate complications: abdominal pain, respiratory problems (for splenic injury), and jaundice. All direct patients back to the emergency room except jaundice, which warrants a phone call to the office for triage since it may represent hematoma mobilization rather than bile leak.↗
▶Ep 2 · 27:27
clinicalIt is extremely rare for any patient who goes home from the hospital doing well to develop a finding that would put them at risk for life-threatening bleed.↗
▶Ep 2 · 27:27
clinicalStudies performing routine ultrasounds found many pseudoaneurysms, but the number was discordant with patients who developed delayed bleeding or complications. Having an asymptomatic pseudoaneurysm does not mean the patient will have delayed bleed or complication; the risk is less than 10% and likely much lower.↗
▶Ep 2 · 27:27
opinionMost patients with spleen injuries do not need follow-up imaging. Patients with liver injuries might benefit from follow-up ultrasound, but this remains uncertain.↗
▶Ep 2 · 28:30
guidelineActivity restriction duration follows the APSA recommendation of grade plus 2 weeks (e.g., grade 4 injury = 6 weeks restriction). This is based on expert opinion, not scientific evidence.↗
▶Ep 2 · 28:30
guidelineChildren with solid organ injury can return to school but need to change classes 5 minutes before other students to avoid hallway contact. They cannot participate in gym class or physical education.↗
▶Ep 2 · 35:38
clinicalEarly recurrent hypotension (patient responds to transfusion, becomes stable, then becomes unstable again before reaching ICU) represents failure of non-operative management. This is different from hemoglobin drifting down in the ICU. The patient needs to go to the operating room or angio suite very quickly.↗
Summaries David gave as host
· 2 summaries
Recaps of other experts' statements, not David's own clinical position.
Summaries David gave as host · Blunt Liver Injury2 summaries
host summaryDavid Notrica summarizing a resource: One massive transfusion trial found that giving blood early and often prevented patients from progressing to require massive transfusion, suggesting early blood prevents DIC.↗
▶Ep 2 · 10:31
host summaryDavid Notrica summarizing a resource: Adult literature shows that excessive crystalloid dilutes the benefit of 1:1:1 resuscitation (Duchesney, New Orleans) and decreases success of non-operative management (John Holcomb). Children are somewhat more resistant to negative effects of crystalloid than adults, but excess crystalloid still causes adverse effects including prolonged ventilation.↗
