Solid Organ Injury Management: Update Course 2017

A normal shock index is less than 1 or less than 0.9, with adjustments now available for pediatric patients

The shock index allows clinicians not regularly seeing pediatric patients to assess for shock without knowing normalized blood pressure values for children

Massive transfusion protocol must be activated as soon as massive bleeding is recognized, not after reaching a specific threshold, to make a difference in outcome

FAST (Focused Assessment with Sonography for Trauma) examines four specific areas: three in the abdomen and one in the pericardial sac, looking only for hemoperitoneum or pericardial effusion, not organ injury

FAST remains useful in unstable patients as a replacement for diagnostic peritoneal lavage (DPL)

The ATOMAC guideline divides patients into stable and unstable categories: stable patients can be transfused to hemoglobin >7 and discharged when bleeding stops; unstable patients who don't respond to packed cells and fluids need operative intervention

Young children with head injury are often hypotensive even without active bleeding, while some bleeding children are not hypotensive, making it difficult to define 'stable' vs. 'unstable'

Hypotension due to solid organ injury is ominous, with significant risk of death and failure of non-operative management

In younger children (not teenagers), blood pressure less than 50 mmHg is a really ominous sign with high risk of poor outcome

Teenagers and adults can become hypotensive, respond to blood transfusion, and often be managed non-operatively, unlike younger children

In patients with traumatic brain injury and shock, resuscitation should be managed based on cerebral perfusion pressure rather than absolute blood pressure when intracranial monitoring is in place

The ATOMAC guideline was modified 8 months into the prospective study to specify that recurrent hypotension or lack of sustained response to packed cells constitutes failure of non-operative management, after a patient with multiple injuries died following recurrent hypotension in the PICU

The ATOMAC guideline effectively guided care for 1,007 pediatric trauma patients in the prospective validation study

Only about half of children in shock are hypotensive, meaning shock does not necessarily equal low blood pressure in pediatric patients

40 mL/kg (or 4 units of packed cells) remains a validated threshold for failure of non-operative management, supported by both expert opinion and military experience data

Blood evacuated from the chest via chest tube may originate from abdominal bleeding through a ruptured diaphragm, making it difficult to determine whether chest tube output should count toward the 40 mL/kg solid organ injury transfusion threshold