Trauma II: Solid Organ Injury

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Sophia Abdulhai, Abdulruf Lamoshi, and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to Stay Current in Pediatric Surgery. This is Todd Ponsky, and today we are recording live from Akron Children's Hospital. And our topic today is blunt solid organ injury. And uh the title that David Norica gave us was Everything You Wanted to Know about Blunt Solid Organ Injury. And that's actually a quite a fitting title for what we're gonna get into. We've already done a previous podcast on uh trauma part one, and this is really trauma. Part two. And with us today we actually have two guest faculty. First, I'd like to introduce my co-host, Dr. Mark McCollum. Dr. McCollum is here at Akron Children's Hospital. He is a staff surgeon here. He's been here for 15 years. He's assistant professor of surgery at Northeastern Ohio College of Medicine. And he is our trauma medical director here at Akron Children's Hospital. Mark, thanks for joining us today. Yeah, thanks for having me talk. And our guest of honor is Dr. David Notrica. David is the trauma medical director at Phoenix Children's Hospital and is associate professor of surgery at the Mayo Clinic College of Medicine and associate professor of surgery at the University of Arizona College of Medicine in Phoenix. David, thanks for joining us. Oh, my pleasure. Thanks for inviting me. Uh, just to give the audience some background on why. We are very excited to have you here is you have clearly recently emerged as the expert in solid organ injury, and a lot of that has to do with an incredible work that you did on something that many of us haven't done, which is really put together a fantastic multi-center prospective study to really better understand all of the elements of solid organ injury called atomic. Can you tell us a little bit more about what atomic is and what you guys did? First of all, um, that is very kind. 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. So while previously there was some evidence on how long you should keep patients in the hospital, no one had ever tried to do a prospective study, and, and the evidence was starting to come out that maybe you didn't need to keep patients in the hospital as long. So we developed the algorithm by looking to see what information was out there, and then we started asking questions and those questions will ultimately became the great publication that we published in the Journal of Trauma and Acute Care Surgery. So the studies that were being done were really showing that you did not need to keep patients in the hospital for a grade plus 1 and that a lot of the limitations that we thought were important probably were not as important. I had amazing collaborators when we started Atomic, and Atomic was started really with 5 hospitals, and we expanded it to 10 hospitals and. Now we're continuing to expand the, the opportunities to do multi-center collaborative research. So, going back to your original question, Atomic is a consortium of hospitals that do research together for trauma. It, it started out with, uh, people that knew each other and, and expanded to more people who knew each other, and then it started doing some really great research that ultimately led to numerous publications that have kind of, you know, put some evidence behind. What we've been doing. This is great, and it's been a true honor for us here in Akin to have been a part of that. So thank you for including us. So let's dive right into, I can tell you that our practice has changed here based on the literature that you've been publishing. Let's go through, there's been certainly, David, a lot of management of solid organ injury based on historical studies or historical publications or at least dogma that we've all been taught, and you're really dispelling a lot of the stuff we've been taught in the past. So let's get into some of the The specifics here. Uh, Mark, did you want to start with that? Sure. So, so David, um, in reference to solid organ injuries we've discussed, can you, uh, can you, uh, flesh out a little bit that in patients with blunt solid organ injury, what is the evidence to support non-operative management based on hemodynamic status as opposed to grade of injury? That's a great question, Mark, because what we started to see from the work done by the folks in Arkansas and then the work that Sean St. Peter did. Um, was that 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. That's how it developed. Steve Stilanos did that and it was really important at the time, because for the first time we were getting CT grades on patients and we didn't know what to do with it. But shortly after that decision was made, um, Sam Smith and the folks in Arkansas said, hey, wait a minute, you can actually manage these patients based on their hemodynamic status. You don't need to know what their grade of injury was, and that led to a paper very early on that said, hey, you divide patients up into stable and unstable, and that's how you manage them. And then nobody seemed to pay attention to that paper, which was a great paper, and they followed it up with another paper called Throwing Out the Grade Book. And if you know anything about trauma literature, it's important to have a great title. And so that paper did have a great title, and, and we looked at it and realized that um that he was onto something. Sean Saint Peter then, uh, did a study where they managed patients based on hemodynamic status and then did a prospective study, and the Arkansas folks did another prospective study and we started to have some real scientific evidence that said, yeah, you can manage patients based on, uh, hemodynamic status rather than grade of injury. That's how we took that first leap, was going from throwing out the grade book effectively, To, um, let's look at the patient. And if you think about it, 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. So, thanks, David, and, and along those lines, so, since we're talking about hemodynamic status and, and hypotension, A little bit, can you help us understand, you know, in children with blunt liver or spleen injury, we know that hypotension is a late finding in hemorrhagic shock. Can you describe some of the other factors that we would use to define hemodynamic stability? You're absolutely right. Let me go back to that because you are 100% right that hypotension is late finding, that by the time kids are hypotensive, it's very, very late. And then you look for the evidence to support it, and you can't find it. You, we all know it. Those of us who take care of injured patients know that that's true. But we couldn't find the literature, you know, to support that. That having been said, we, since that time, since the original study, we actually went back and did, uh, do that research and did show that, um, hemodynamic status is a late finding and most patients that need to be transfused, almost half the patients who need to be transfused early are not hypotensive. So, that's half the answer to the question. The other answer to the question about, um, what to use in order to define who's stable and unstable was incredibly problematic because even though you and I know. What a stable patient or an unstable patient looks like. When you go to define it, it becomes extremely difficult. So, some patients who have concurrent head injuries may not have, um, uh, tachycardia. If you're an adult patient, you have hypotension, and you know that they're, that they're unstable, but some pediatric patients are unstable and not hypotensive. Some patients are tachycardic, uh, due to pain and are not actively bleeding. And so ultimately we had to abandon the terminology stable and unstable. And we changed the terminology to patients who were bleeding or having bled recently. I will go further and tell you that 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. A matter of fact, you, you often don't know if they're still bleeding until you give them blood. And they proved that they're still bleeding. That was a very, very difficult concept for adult trauma surgeon, but for pediatric surgeons, we all kind of knew in the back of our mind that a patient who comes in looking shocky may or may not still be bleeding, because often they'll bleed a bit and then stop. They'll be in shock, but they won't continue on bleeding. Um, kids have an amazing ability to stop bleeding and far superior to adult patients. Do you use then in your center, vital sign indexes like the shock, Index or laboratory values like serum lactate in addition to physical exam findings. So the SIPAA, which is the shock index pediatric adjusted, was first described from the folks in Denver, Colorado, so accurate et al. and they basically said, yeah, you can use the shock index, which is the heart rate divided by the blood pressure. But what the pediatric adjusted shock index does is it says it takes the old adage, which is that if your heart rate is higher than your blood pressure, you're in trouble. And then it looks at it for kids and says, actually, if your heart rate is, you know, 1.1 times your blood pressure, then you're in trouble. And, um, it kind of just made an adjustment for kids. It turns out that what shock index does for you, it is it allows you to identify patients who are not currently in shock. It, it misses very few patients who are in trouble. So if your shock index is not elevated, there's, A very low likelihood that your patient is experiencing hypovolemic shock, and that's how we use shock index. Unfortunately, we have a fair number of patients who have elevated shock index who are not actively bleeding or not hypovolemic, but the converse, which is that if your shock index is not elevated, those patients are probably not actively bleeding. Yeah, and just for reference, shock index is defined, as you mentioned, as heart rate over systolic blood pressure. And the cutoffs that we've used in uh in pediatric trauma is between ages 4 and 6, a shock index greater than 1.2. In ages 7 through 12, a shock index greater than 1.0. And then in kids older than 13, they follow along the lines of the adult literature, which, which suggests shock index of greater than 0.9 indicates instability. And for those of you who are listening to this podcast on the Stay Current app, uh, we will Have attached all of the references and all of these numbers that Mark just read off. We'll have those in the text section of the podcast. So Dave, another thing is we're we're moving along with these trauma resuscitations in these children with blunt liver or spleen injuries. A hot topic currently is resuscitation. And what fluid should be used. So from a crystalloid infusion standpoint, what are your thoughts as far as limiting crystalloid infusion in patients that you know are actively bleeding, not crystalloid, but bleeding blood? I think you've got to start with the old adages that they're not bleeding crystalloid. The thing that we have figured out is that if you want your patient to survive, giving them a tremendous amount of crystalloid is not a good way to do it. So, let me start with where we were at before we started the, uh, Atomic publication, which is you had ATLS saying that you effectively gave 60 mL per kg of crystalloid before you went to blood, and the adult literature was really showing that adult patients who got a lot of. Crystalloid did not do as well. You actually diluted out the benefit of 1 to 1 to 1 resuscitation. That was shown by Duchesney, uh, in New Orleans. We started to see from work from John Holcomb that your chance of managing patients non-operatively went down if you gave a lot of crystalloid. And so there was pretty good secondary evidence to suggest that after you've given a patient 20 mL per kilo of fluid, that it's time to start blood transfusion, if you want to manage them non-operatively, and if you want to have a good outcome. And the evidence to support that was really pretty good. Now, there was some evidence that children were a little bit more resistant to the negative effects of crystalloid than adults, but even in that paper, which, which was another Denver paper, the patients who got excess crystalloid still had some adverse effects, including being on the ventilator longer. So really strong, uh, tangential evidence to support it and some great head-on evidence on adults to. Support switching to blood transfusion early, and, uh, that's how that got into the atomic algorithm. And now that we've been doing that and become very comfortable with it, we are really happy with it. The other thing that happened was one of the trials that was set up to look at massive transfusion, or 1 to 1 to 1 transfusion, uh, found that when they gave, uh, blood early and often, that not as many people went in to require a massive transfusion. And that I think speaks worlds to the effectiveness because 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. I think for me and for everyone else, that was probably one of the more important things that I've learned from what you've been publishing is that's a huge paradigm shift to give blood earlier than we had been taught. But when you're looking at The outcomes you were noting the benefits of giving blood early. I mean, the reason it was designed, I think, to give a lot of crystalloid early on is just we just didn't want to transfuse patients. What about the complications of transfusion short term and long term, and how do we know that that is now not going up because we're giving more blood? Todd, that's a great question. You know, we're starting to do some work on massive transfusion, and I know Mark's doing some. Studies on massive transfusion in kids. They're hard studies because there are not that many children that are massively transfused. And so when you have a relatively small population receiving the massive transfusion protocol, and the complications of it are fairly rare, it's going to be hard to know that, that this is completely safe. That having been said, what we know from the, from the adult series, because they have a lot more patients with massive transfusion protocol, um, is that it does seem to be safe and it does. to be the right thing to do. So Dave, I think that's a pretty nice segue into the next, the next point I'd like your comments on, and that is, as we move into blood transfusions, you know, we've been taught in a lot of, we're all still kind of on the heels of our massive transfusion protocols, and we were arguing about ratios of 1 to 11 to 1 to 1, 1.2 to 1, and it seems like now real time viscoelastic assays, tag or rote are getting a lot more traction. So that we're directing component therapy specifically as opposed to shotgunning a transfusion. I'd love your thoughts on that. That is a great point. So directed resuscitation, so using the tag and the rotam, I think makes a lot of sense from a theoretical standpoint. In my institution we do that. We actually use tag and rotam to guide the therapy. I think we use TEG technically. It's much harder to find great evidence to say, yes, this is the, the, the right thing to do, just because the numbers are small, same problem that we had before. But like I said, right now we're doing directed therapy, and I think if there's a, if there's a randomized controlled trial comparing 1 to 1 to 1 or 1.1 to 1 to 1 versus TG in children, that will ultimately answer the question. I, I don't know that we have the answer right now. Yeah, I agree, but those numbers are starting to come back and we're seeing more and more data that suggests. Directed component therapy not only saves money, but it saves product and more efficiently can resuscitate a patient than the shotgun approach of ratio driven massive transfusions. I would have to agree, and you know at some point I thought we were going to have whole blood more readily available, so it didn't matter whether or not we had the components. We were just going to get back with they were bleeding, but we still don't have that available in Phoenix, and I'm hoping that the adult centers drive the desire and the need and the availability of whole blood transfusion for trauma. Yeah, I think it is making a comeback. We're seeing one hospital in particular in our region that's using whole blood as well. So thoughts then on the patient who has ongoing bleeding, is hemodynamically unstable, and you're in the process of resuscitating them with blood products. What are your thoughts on angioembolization, its safety and efficacy in pediatric blunt, liver and spleen injury? Let me take the question separately. So from a safety standpoint, I think we've proved safety. So I think angioembolization is safe. Efficacy is a much harder question because we know that, um, a lot of patients who have contrast extravasation on CT will stop bleeding even without angioembolization. What we saw in our failure patient is that none of the patients who got embolized for splenic bleeding went on to fail. So that's good news. But a lot of the patients who had angioembolization for liver bleeding, um, did ultimately go on to need a laparoscopy, a washout, another procedure. A lot of those were converted from active bleeding to, Managing bile complications or, or managing a lot of blood in the abdomen. So there were good evidence to support that, that the angioembolization was helpful even in the hepatic injury patients. I, I think that the data is supportive angioembolization for splenic injury and for hepatic injury. Not every patient who has contra extravasation needs an angioembolization because so many of them will stop. So you really need to look at your patient and if they're continuing to bleed, then that patient needs to, to have angioembolization. We captured that in the algorithm by saying, look, the criteria for angioembolization is similar to the criteria for failure of non-operative management. If they don't stop, if you're having to give blood, then yes, take them to the angio suite if they're stable enough. Yes, certainly, and an anecdote regarding that recently was a patient, a multi-organ injured patient that we had recently who had not only a grade 5 splenic injury with active extravasation on. CT scan but also had a hepatic injury and a renal injury. Interestingly, we took him to the angio suite. We got a nice spletogram, but there was no active extravasation at the time of injury. Now we went on to work on the additional bleeding from the other organs, but it was interesting that this massive extravasation on CT scan was not actively bleeding 45 minutes later when they were in the IR suite. Children are absolutely amazing, and all of the things that we have to do to keep adult patients alive. May not benefit children. That is the hardest part about changing the paradigm for managing children is that they don't behave like adults. So once we have these patients resuscitated and stable in kiddos with solid organ injury, should ICU admission be determined then by injury grade, hemodynamics, or a combination of both? You know, that's a great question. And before I wrote the paper, I was absolutely certain that hemodynamic status was the only thing that mattered and that we could save a lot of ICU stays. When I actually did the literature search, that was supported up until grade 5. So, if you have a grade 1 through 4 injury, you can definitely say, all right, well, we will, if they're hemodynamically stable or if they're not actively bleeding, they can be managed on the floor safely. But for the grade 5 injuries, there was enough evidence to suggest that those patients in and of themselves, based on the grade of injury, weren't an ICU. That, yeah, I would recommend grade 5 injuries go, go to the ICU. Grade 5 injuries that are hemodynamically stable, it's a very small subset of patients who could potentially be managed on the floor with a grade 5 injury, so it's not a big deal. Most grade 5 injuries, um, will have bled significantly and would have gotten into the ICU based on that, but those patients with grade 5 injuries need to be in the unit. So on those patients, either on the unit or on the floor, do you have a threshold of volume of transfusion that would then indicate. Failure or is it a case by case? So there's good evidence that we finally have a threshold for failure, and the threshold is 40 mL per kilo of all blood products, and that data came to us from NEF and the military experience. They're the ones that showed that if you got transfused more than 40 per kilo of blood products, you were more likely to need operation and more likely to die. And we'd all kind of felt that 40 per kilo was the cutoff. In some of the expert panels they had said yes, 40 per kilo is a failure point. We didn't have great evidence going into it, but now that we've really started to say yes, that's the failure point, it seems to hold up really well. Yes, and that's the threshold that we'll use in most cases once we have these children resuscitated. Admitted to the floor of the ICU and stabilized, you know, on rounds the following day, you see them, and they're up and around jumping on the bed like it's a trampoline. What are your thoughts as far as time frame for bed rest? How long and what are the parameters that help you decide? I'll give you a little background on bed rest. 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. 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. You're absolutely right, they were not resting in bed. They were jumping on the bed. Sean St. Peter said, yeah, they're they're anything but resting, and there's not much literature to support bed rest. Matter of fact, there's no literature to support bed rest. There's one study in an adult where they compared adults who were given bed rest and those that were not. And there was no increased incidence of bleeding. The problem that we ran into is that almost every study that, that we wanted to reference had used bed rest, even though there's no evidence to support it. My personal feeling is that I don't think bed rest does anything. Uh, we were able to eliminate it in our renal injury, uh, protocol because, um, we had studied those patients and found out it makes no difference for renal injury, whether you're, you're, um, uh, walking. Around going to the bathroom or whether you're on strict bed rest, and I don't think that it makes a difference for a liver or spleen injury. I don't think that taking an injured organ and walking it to the bathroom is going to suddenly cause it to bleed. So along those lines in kids that then are hospitalized for observation with a blunt liver or spleen injury who show really no signs of bleeding, no evidence of hemodynamic instability, no drop in their hematocrit. Do you use a time frame for observation, or are they able to be fast tracked and maybe discharged within 24 hours? That is a great question, and Sean St. Peters answered that for us in a prospective study and then I did a follow up on it. And so, um, yeah, actually it turns out you don't need to have him in the hospital for a minimum period of time. Most of these kids come in in the afternoon or evening, and they're hospitalized quote unquote overnight and then sent home the next day. Trying to pin down how long that was was a. A Little bit problematic and what we came up with a protocol that says, yeah, we need to keep them in the hospital for 18 hours, and if they haven't bled in 18 hours, then they're very unlikely to bleed, and that was incredibly powerful for us to limit the amount of time they're in the hospital. We further supported that by showing that the patients who were transfused and the patients who were failed, failed non-operative management all failed early, and that further supported the fact that if you hadn't failed in 18 hours, you're probably not going to fail. And when it, when it comes to day to day. Variability in checking hematocrits or in some cases hour to hour variability if we're checking them every 6 hours. Do you have a criteria or a threshold, a hematocrit or a hemoglobin point that indicates lab variability versus actual continued bleeding? We checked serial hemoglobin so long that we saw hemoglobins go down in patients who are not bleeding, and the reality is they go down for a variety of reasons lab error being drawn incorrectly. If they're drawn upstream from an IV, it goes down. We dilute them out with too much fluid, they go down. Um, ultimately, the better criteria for whether or not a patient is bleeding is not serial hemoglobins, it's physical examination and vital signs. And so if your patient's heart rate is continuing to go up, you have a problem. If your patient is showing clinical signs of poor capillary refill or pallor, um, or cold extremities, those are the signs that let you know the patient's bleeding, and, uh, there's good evidence to suggest that serial hemoglobins are not necessary, that you don't need to follow a serial H&H. On a stable patient that you should follow the physical examination and the vital signs, and that will identify every patient who will need transfusion and every patient who is failing non-operative management. Yeah, very good, and I think that underscores the importance of serial examination by a primary examiner as opposed to the shift mentality of a different resident every day. I agree with you, although I don't think we'll ever get back to the work hours that you and I had in training. Uh, but you're absolutely right. More importantly, you know, um, half the patients who fail non-operative management do it because they develop peritonitis, not because they continue to bleed. So, whenever these kids are ready to go home, do you have a standard follow-up regimen of a week, 2 weeks, 4 weeks? The rest issue, I'll let you discuss as well, as far as time frame where they really stay off of activities until you see them back. So, um, you know, the timing the follow up was, Interesting. What we found is that a lot of patients with low grade injuries never showed back up for follow-up. And so when you think about all the grade 1, grade 2 injuries who no showed for their clinic appointment, we thought, well, we should find out something about these kids, and since there's such a low incidence of there being anything that we do for the kids at the follow-up appointment, we started doing telephone follow-up. And um, what that did for us is it actually let us know that the kids were OK, and it also prevented them missing even more. school, because they already missed some school. And so we do telephone follow up for low grade injuries and, uh, we bring back the patient, uh, for follow-up with higher grade injuries. That having been said, um, we haven't found anything of any use in the follow-up visit. And I know as surgeons, we love our follow-up visits and we think that they're super important, but ultimately, 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. That's a great point, and that kind of leads me to my next question, which I think you partially answered, and that is, is there a type of injury, a finding on imaging or a symptom that would then maybe move you to schedule additional imaging in follow up to avoid a complication like a pseudoaneurysm or an AV fistula or something along those. It came to figuring out what patients were, were having complications or which ones needed follow up. We were in an information free zone. And so what we did was we looked through the literature to find all of the complications of non-operative management that we could identify, and we converted those complications into symptoms and listed those in the discharge instructions. So what patients that are having complications come back for is they come back for abdominal pain. They come back for respiratory problems. So you have a splenic injury and they, and they're having trouble breathing. That brings them back to the emergency room. So we just took that whole group of problems and put it into the, this is what you watch out for, and we put those in the atomic discharge instructions. And basically all of them direct the patient back to the emergency room, except for jaundice, which, um, is fairly common if you've got a big hematoma, um, they do get jaundiced, uh, even though they're not having a complication, and, uh, we directed them to call the, Office, even if you're jaundiced because you're having a little bit of a bile leak or a myeloma, most of those patients can at least be triaged with a, with a phone call so they don't automatically have to go to the emergency room. You clearly don't want to miss a patient with a bile leak and keep them at home, but a lot of times you can determine whether or not they've got a bile leak or if they're just mobilizing the hematoma just by talking with a mom or talking with the patient. So then even in a grade 4 or a grade 5 injury with active extravasation. There's no real utility then in scheduling a post or a follow-up ultrasound or additional imaging. Yeah, that's still a really tough question. So my personal opinion is that, is that most patients, that patients with with spleen injuries don't need it. There's a possibility that patients with liver injuries. Might benefit from having a follow-up ultrasound. In studies where they did routine ultrasounds of, of every single patient, they found a lot of pseudoaneurysms. Matter of fact, they found so many pseudoaneurysms that it was so discordant with the number of patients who have delayed bleeding or delayed complications that just having a pseudoaneurysm of itself does not mean that you're going to go on to have a delayed bleed or a delayed complication. But we don't know what subset of those patients with asymptomatic pseudoaneurysms really are going to go on to have problems. It's certainly less than 10%, but it may be even less than that. My guess is, based on the, on the study that we did, that it's going to be extremely rare that any patient who goes home from the, Hospital doing well would develop any finding that would potentially put them at risk for a life threatening bleed or anything of that nature. Thank you for the very nice review, the atomic guidelines, specifically the grade paper and current management and evaluation of blunt liver and spleen injury. So David, we've touched on evaluation in hospital management and We have a patient who has stabilized to the point that he is ready for discharge. What criteria do you use then for time frame of follow-up? We switched to a follow-up that was really based back on grade. So if they have low grade injuries, we do telephone follow-up on those patients, and the patients with higher grade injuries, we do ask them to come back for a follow-up visit. Um, that having been said, the patients who do follow up with those grade 345 injuries, at no point did we find anything particularly useful or helpful about that follow-up visit. The patients who had problems ended up coming to the emergency room. Um, you know, either before or after the visit, and when you really break down to what that, uh, follow-up visit did for them other than have them miss an extra day of school, it's hard to point to any benefit for that in-person follow-up. The nice thing about the telephone follow-up for the low grade injuries is it did allow us to know whether or not we were doing the right thing. And so from a study standpoint, it was great, but from a practical standpoint, I don't know that you need to drag. Those patients back into the clinic. Regarding activity restrictions, I'm gonna answer that in two ways. So it turns out with the activity restrictions that you need, there's no reason that those children cannot be back at school. They may need to change class 5 minutes before the other kids so they don't get roughed up in the hallways. Um, kids can do a lot of bumping and contact sports, uh, in the hallways, but they definitely can be back at school. They just can't be in gym class or physical. Education class and then for how long that is, the activity restriction, um, we didn't have any evidence for how long you needed, um, activity restrictions, so we defaulted back to the ABSA recommendation, which was grade + 2 in weeks. So grade 4 injury at 6 weeks. I don't know that there's science behind that. A matter of fact, I'm, I'm pretty certain there's not science behind it, but there is expert opinion behind it, and at some point we'll have to do some research. Figure out whether or not they really need those activity restrictions to answer that question. If you don't mind, I'd love to just kind of go through point by point. We took some notes and I'd like just to review for the audience some of the points that you made. Please jump in if I've summarized them incorrectly, but I think we started by you presenting an abundance of evidence that supports non-operative management based on hemodynamic status rather than grade of injury. And that's been a long time coming. In addition, I think we discussed the hemodynamic stability and how hypotension is a late finding in children that are in hemorrhagic shock, and clinical exam findings like pallor, poor distal perfusion, serum lactate, maybe shock index, as well as tachycardia all can play a more significant role than actual hypotension when defining the child in hemorrhagic shock at an earlier stage. I think you also pointed out nicely that there really is a limitation to the amount of crystalloid that should be infused. Prior to consideration or actual transfusion of packed red cells, and that's at 20 ccs per kilo of crystalloid. If a patient's actively bleeding, crystalloid is not the fluid they need. We also touched on patients with solid organ injury that do need transfusion, whether we should be transfusing them packed red blood cells, utilizing massive transfusion early with transfusion ratios of 1 to 1:1, or if we should be directing blood component resuscitation based on real-time viscoelastic assays. And I think those certainly are coming around and are going to be the standard of care soon for the audience that comes from all over the world. Could you be more clear about the 1 to 1:1 ratio? Yeah, that's a ratio of blood products used in transfusion and broken up since we don't use whole blood because of cost and availability, we then break up the components of the blood into packed red cells, platelets, and FFP, and that would be the 1 to 1:1 ratio of those three components. So we also touched a little bit on angioembolization and blunt liver and spleen injury, and Although we know it works, the interesting part is in spleen injuries, non-operative management works in almost all cases, and so really there's not a great added benefit for patients that need intervention. If they need intervention and they're unstable, splenectomy in most cases is the way to go. It is useful, however, in patients with multiple solid organ injuries like a combined spleen, liver, or spleen kidney injury so that you can manage active bleeding in one or two of the organs, not knowing specifically what your source of hypotension. We spoke a little bit about children requiring ICU admission, and that should be determined by clinical judgment, including both consideration of grades, specifically grade 5 injuries, and any hemodynamic instability. We talked about probable lack of need of specific bed rest requirements in these patients, and that early mobilization and limited activities would certainly be safe. We talked about as well bleeding patients with solid organ injury and what would indicate clinical failure. We've stated that that's been fairly well established. In the literature that a 40 cc per kilo blood transfusion would indicate clinical failure. Now that needs to be put in perspective given the patient's hemodynamic status and where you are on the evaluation management curve, but 40 ccs per kilo of blood transfusion would indicate a failure in most cases. We've also touched on patients with blunt liver and spleen injury, the time frame for hospitalization, and we've decided that in most cases patients with chemodynamic stability and no continued blood. Loss can be safely discharged within 24 hours. And finally, there's no real need in the asymptomatic patient, despite the grade of injury or early imaging findings. Those patients in most cases do not need additional imaging, although you have to take that case by case. But patients with significant complications related to blunt liver or spleen injury often present with symptoms. Dave, before I let you make any final comments, I want to direct the listeners to The paper that most of this has been published in that David had the lead authorship on, it's called Non-Operative Management of Blunt Liver and Spleen Injury in Children Evaluation of the Atomic Guideline Using Grade. This was published in the Journal of Trauma Acute Care Surgery in 2015. David Norica is the lead author of this paper, and in the paper, each one of these questions is addressed and answered very clearly. So this is absolutely a paper. That everyone should have printed in their office. This is one of those Sentinel papers that you'll be referring to. Repeatedly, mostly because of the second page of the paper that has what I've been, uh, referring to all the time here in Akron is the algorithm that David has created using these questions about how to manage a patient with solid organ injury. It takes you through all the different situations and how to manage these patients, and it is spectacular. These do hit on all of the radical changes. that Mark and David just pointed out that have totally changed the way we've been taught to manage trauma patients, giving early blood, not necessarily having those strict criteria for discharge or activity. These things are very new and need to be understood by everyone because this is a big change in our field. David, do you have any final comments? I think the main comment is that, you know, even though I was the lead author of this paper, this was the Work of a lot of people and so the co-authors that you see on the paper all helped develop this and you know by the time that we had an algorithm that we were taking to study prospectively, we were on the 11th version of this algorithm and we learned a lot in the process about, you know, how to make it, how to operationalize the algorithm, but we also learned something that kind of snuck in there around the 9th edition, which is that. If you have recurrent hypotension, or, or if you fail to have a sustained response to that first blood transfusion, you failed. And so, and that was critically important because we did have a patient who responded, became stable, went to the CT scanner, and then became unstable again. And the decision was made to try and, and continue to manage that patient non-operatively. And we, I don't think we had really considered, uh, that particular scenario when we, when we first were developing the guideline, and we realized that, yeah, early recurrent hypotension is a failure. It's not like being in the ICU and your hemoglobin drifting down. You didn't make it to the ICU yet. That patient really needs to go to the operating room or at least go to the angio suite very quickly. I want to thank both of you. This has been a very important audio chapter because this is so radically different than what we've been taught in the past and finally based on good multi-center data, I think we probably will need Part 3 and Part 4 and maybe Part 5. For trauma because there's so much that goes into it, but this is a great start. Like I said, we'll put all this in the, uh, text attachment to the podcast for everyone to read, and, uh, I want to thank again both of you for a fantastic, uh, recording. Thank you very much. Yeah, thank you. I appreciate it. I really appreciate the opportunity to speak with you guys. Thanks, David. All right, have a great day. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Please send questions or comments to us at staycurrent podcast@gmail.com. We'll see you next time.