Richard Falcone

44 statements · 1 topic · summaries given as host listed separately

Colorectal / ARM & Hirschsprung · guest expert

Featured statements

▶ Ep 2 · 4:50
One of the things that we do, um, not infrequently at all, is leave a kid in a C collar, and we admit them to the hospital in a C collar. I would say 90% of those kids the next morning, um, when they're, they're less distracted, they're not in the trauma bay, um, we can, we can clinically clear the C-spine on rounds the next morning.
quote · Traumatic Brain Injury
▶ Ep 2 · 39:40
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 FAST 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 · Traumatic Brain Injury

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Richard's statements about Traumatic Brain Injury 44 statements

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Pediatric Trauma With Dr. Richard Falcone

▶ Ep 2 · 3:08
clinical Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 patients per year. ↗
▶ Ep 2 · 3:32
clinical At Cincinnati Children's, the ED physician serves as team leader for all traumas, chosen because they are present when the patient arrives. ↗
▶ Ep 2 · 4:32
epidemiological The ultimate risk of C-spine injury in pediatric trauma is actually pretty low. ↗
▶ Ep 2 · 4:50
quote One of the things that we do, um, not infrequently at all, is leave a kid in a C collar, and we admit them to the hospital in a C collar. I would say 90% of those kids the next morning, um, when they're, they're less distracted, they're not in the trauma bay, um, we can, we can clinically clear the C-spine on rounds the next morning. ↗
▶ Ep 2 · 4:50
clinical 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. ↗
▶ Ep 2 · 8:27
clinical Getting CT early in kids with normal neurologic exam and persistent tenderness is not useful because you won't feel comfortable removing the collar based on imaging alone without clinical improvement. ↗
▶ Ep 2 · 9:50
clinical There is enough evidence now that you don't need to get an X-ray on every awake child without distracting injuries and no midline tenderness. ↗
▶ Ep 2 · 11:40
quote 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. ↗
▶ Ep 2 · 12:11
quote These kids can give you a reliable exam no matter how, you know, anxious and distracted, and as pediatric surgeons, we do that all the time for appendicitis, you know, distract the kid and get a good exam. We can do the same with our trauma patients. ↗
▶ Ep 2 · 21:35
quote 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. ↗
▶ Ep 2 · 21:35
clinical The challenge in pancreatic trauma is determining whether there is a duct injury or not, which is the number one question and concern. ↗
▶ Ep 2 · 22:00
clinical There is more and more evidence that if you have a true duct disruption, a distal, ideally splenic-preserving distal pancreatectomy early is better treatment for grade 3 pancreatic injuries. ↗
▶ Ep 2 · 23:20
clinical ERCP has advantages (potentially therapeutic with stent placement) and disadvantages (risk of inducing pancreatitis by injecting dye), while MRCP doesn't have the pancreatitis risk. ↗
▶ Ep 2 · 24:10
clinical Conservative management of pancreatic duct disruption can work and pseudocysts are manageable and drainable, but this approach takes longer with more TPN time and longer hospital length of stay compared to early pancreatectomy. ↗
▶ Ep 2 · 25:00
opinion Centers that perform frequent pancreatic operations and are comfortable with laparoscopic distal pancreatectomy are more likely to have good outcomes with surgical management of pancreatic trauma. ↗
▶ Ep 2 · 26:20
quote Yeah, and I think that's absolutely right. I think that's what more and more of the literature's, you know, agreeing exactly what you're saying on both accounts. ↗
▶ Ep 2 · 26:40
clinical There is more of a trend toward considering operating on pancreatic duct injuries more frequently, and if you're going to do it, you want to do it within the first 24 hours. ↗
▶ Ep 2 · 27:28
clinical If you go in to operate on pancreatic trauma and find parenchymal injury but not ductal disruption, you should just drain and get out rather than proceeding with distal pancreatectomy. ↗
▶ Ep 2 · 29:40
clinical Cincinnati Children's was more likely to do skeletal surveys and involve social services for low socioeconomic status or minority children with head injuries compared to middle/upper class non-minority families. ↗
▶ Ep 2 · 30:20
epidemiological Abuse happens in all races and all socioeconomic bands, though economic stress does add some risk. ↗
▶ Ep 2 · 30:30
quote Abuse happens in, in all, in all races and all socioeconomic bands. ↗
▶ Ep 2 · 30:50
clinical Cincinnati Children's implemented universal screening: any child under 2 admitted with a head injury from an unwitnessed mechanism (not witnessed publicly, not motor vehicle collision) gets skeletal survey and social work evaluation. ↗
▶ Ep 2 · 31:40
epidemiological After implementing universal screening criteria for non-accidental trauma, the percentage of positive abuse cases remained at nearly 50%, despite evaluating more children, indicating the protocol was finding previously missed abuse cases. ↗
▶ Ep 2 · 31:40
quote 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. ↗
▶ Ep 2 · 32:30
opinion A screening test that gives nearly a 50% positive rate of abuse is more productive than most screening tests we do for other things. ↗
▶ Ep 2 · 32:30
quote To me, for a screening test that gives you a nearly a 50%, you know, positive rate of, of abuse, um, that's more, that's a more productive screening test than most screening tests we do for other things. ↗
▶ Ep 2 · 33:09
clinical Families find universal non-accidental trauma screening more reassuring because it's easier to say 'we do this for every family with this type of injury' rather than making it seem like a judgment about the specific family. ↗
▶ Ep 2 · 33:09
quote 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. ↗
▶ Ep 2 · 33:23
clinical Ophthalmologic exams are not routine but are obtained if the skeletal survey is positive or if there are other concerning findings like bruising or abnormal head findings that don't fit the given story. ↗
▶ Ep 2 · 37:00
clinical Abnormal LFTs greater than 150-200 indicate a good chance of some sort of abdominal injury, but normal LFTs provide very little evidence that you're safe, so they may be useful as screening but not for ruling out injury. ↗
▶ Ep 2 · 37:50
clinical Cincinnati Children's has gone away from getting LFTs, amylase, and lipase as routine; they only get them if there are other indications to scan (abdominal bruising, tenderness). ↗
▶ Ep 2 · 38:30
opinion Normal labs don't prove you don't have an abdominal injury, they just make us feel better and give a false sense of security. ↗
▶ Ep 2 · 38:30
quote Normal labs don't prove that you don't have an injury, they just make us feel better. ↗
▶ Ep 2 · 39:40
quote 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 FAST was developed, the hypotensive patient you're trying to prove, do they have a bunch of blood in their, in their abdomen or not. ↗
▶ Ep 2 · 39:40
clinical FAST is great for hypotensive patients to determine if they have blood in their abdomen, which is the classic reason FAST was developed. ↗
▶ Ep 2 · 40:10
clinical A negative FAST in a stable, healthy child may still miss injuries if you trust it too much. ↗
▶ Ep 2 · 40:30
quote A negative FAST in, in a kid that's otherwise stable and healthy literature would still caution you that there's a you may miss stuff if you trust that too much. ↗
▶ Ep 2 · 41:50
clinical At Cincinnati Children's, it has been 4-5 years since they used angiography/embolization for a solid organ injury, though they use it for pelvic trauma and other reasons. ↗
▶ Ep 2 · 42:30
clinical Angiography for solid organ injuries is used more often at adult centers, and there has been a trend of embolizing when seeing a blush or bad injury rather than waiting to see how the patient does. ↗
▶ Ep 2 · 43:10
clinical There is no good evidence that seeing a blush on imaging mandates intervention; a blush puts you at higher risk for needing intervention or transfusion but doesn't mean you will need it. ↗
▶ Ep 2 · 46:10
clinical You can mobilize children with solid organ injuries much more quickly from bed rest than originally outlined in Stylianos's paper, without the slow progression that was initially recommended. ↗
▶ Ep 2 · 48:10
clinical There is growing support for less lab draws, shorter length of stay, and less bed rest for solid organ injuries in children. ↗
▶ Ep 2 · 48:28
clinical Cincinnati Children's protocol for solid organ injuries: grade 1 gets one 12-hour lab check, grade 2 gets two checks, grade 3 gets two checks or possibly a third based on clinical exam. ↗
▶ Ep 2 · 49:10
clinical Grade 1 isolated spleen injuries may not even need hospital admission because they never get transfused and never have problems. ↗

Summaries Richard gave as host · 22 summaries

Recaps of other experts' statements, not Richard's own clinical position.

Summaries Richard gave as host · Traumatic Brain Injury 22 summaries

Open the Traumatic Brain Injury collection →

Pediatric Trauma With Dr. Richard Falcone

▶ Ep 2 · 6:04
host summary Richard Falcone summarizing a resource: The Trauma Association of Canada Pediatric Subcommittee published evidence-based C-spine clearance recommendations in the Journal of Trauma 2-3 years ago, emphasizing clinical exam as the first test. ↗
▶ Ep 2 · 7:00
host summary Richard Falcone summarizing a resource: For children greater than 8 years with normal X-rays and normal neurologic exam, re-examination is recommended; if the repeat exam is normal, the C-spine can be cleared without further imaging. ↗
▶ Ep 2 · 7:30
host summary Richard Falcone summarizing a resource: CT or MRI of the C-spine should only be considered for patients with abnormal neurologic exam findings. ↗
▶ Ep 2 · 16:07
host summary Richard Falcone summarizing a resource: A multi-site study published in Journal of Trauma around 2009 developed a point system for C-spine injury risk in children under 3: 3 points for GCS <14, 2 points for GCSI score of 1, 2 points for motor vehicle collision, 1 point for age 2-3 years. ↗
▶ Ep 2 · 17:30
host summary Richard Falcone summarizing a resource: Children under 3 with a C-spine risk score of 0 or 1 had a 0.0% chance of C-spine injury and don't need imaging. ↗
▶ Ep 2 · 18:00
host summary Richard Falcone summarizing a resource: Children under 3 with a C-spine risk score of 7 or 8 had about a 21% chance of having a C-spine injury and need imaging. ↗
▶ Ep 2 · 18:30
host summary Richard Falcone summarizing a resource: Pediatric Level 1 centers were getting C-spine CTs only 17% of the time compared to adult centers which were getting them 24-45% of the time, indicating adult centers are doing too many CTs overall for pediatric patients. ↗
▶ Ep 2 · 28:50
host summary Richard Falcone summarizing a resource: There is literature showing that if you see someone who looks like you and is from the same neighborhood, you're less likely to be suspicious of child abuse even with the same injury pattern, compared to someone from a lower socioeconomic group or different racial/ethnic background. ↗
▶ Ep 2 · 28:50
host summary Richard Falcone summarizing a resource: There is literature that says, well, if I, if I see someone who looks like me and, um, is from the same neighborhood as me, um, I'm less likely to, to be suspicious of them as, as abusing their child, even with the same injury pattern. ↗
▶ Ep 2 · 35:00
host summary Richard Falcone summarizing a resource: The Pediatric Emergency Care Research Network published criteria in Annals of Emergency Medicine 2013 identifying children at very low risk (0.1% chance) of clinically important blunt abdominal injuries: no abdominal wall trauma, GCS 14-15, no abdominal tenderness, no thoracic wall trauma, no abdominal pain, no altered breath sounds, and no vomiting. ↗
▶ Ep 2 · 36:24
host summary Richard Falcone summarizing a resource: If the very low risk criteria were followed strictly and everyone else was scanned, it would actually recommend more CTs than pediatric trauma centers are currently doing. ↗
▶ Ep 2 · 39:00
host summary Richard Falcone summarizing a resource: Eric Scaife from Utah published that FAST was being used to screen low-risk kids but was giving false sense of security because of the low sensitivity of FAST, which is very user-dependent like any ultrasound test. ↗
▶ Ep 2 · 44:00
host summary Richard Falcone summarizing a resource: Dr. Stylianos's 1999 paper with the American Pediatric Surgical Association Trauma Committee was a landmark paper that changed how everyone managed spleen and liver trauma, and adult trauma surgeons followed pediatric surgeons' lead. ↗
▶ Ep 2 · 44:50
host summary Richard Falcone summarizing a resource: Sean St. Peter and the Kansas City group published papers showing we can shorten bed rest windows: grade 1 and 2 solid organ injuries need at most overnight (12 hours), and maybe two nights for grade 3 or 4 injuries. ↗
▶ Ep 2 · 45:40
host summary Richard Falcone summarizing a resource: By shortening bed rest for solid organ injuries, you can cut down significantly on length of stay without having readmissions or complications. ↗
▶ Ep 2 · 46:38
host summary Richard Falcone summarizing a resource: There is growing evidence that very few grade 1 solid organ injuries, if any, are going to need a transfusion, so all the lab draws initially outlined in Stylianos's paper probably aren't necessary. ↗
▶ Ep 2 · 47:20
host summary Richard Falcone summarizing a resource: Dennis Bensard's group from Colorado presented at Western Trauma Association proposing not doing any lab draws for solid organ injuries if the patient is clinically OK (not tachycardic, no pain, no vital sign changes), using labs totally as directed by physical findings. ↗
▶ Ep 2 · 50:00
host summary Richard Falcone summarizing a resource: A multi-center prospective analysis published in 2012 examined pediatric trauma activation criteria, finding that the American College of Surgeons' 6 required criteria are generic, adult-based, and lack strong evidence. ↗
▶ Ep 2 · 50:50
host summary Richard Falcone summarizing a resource: The multi-center study matched activation criteria to resources used (intubation, blood transfusion within 30 minutes, chest tube within 30 minutes, CPR within 30 minutes, OR within 60 minutes) rather than ultimate injuries sustained. ↗
▶ Ep 2 · 52:00
host summary Richard Falcone summarizing a resource: The evidence-based trauma activation criteria identified were: penetrating wound to head/neck/torso, age-appropriate tachycardia or poor perfusion, receiving blood prior to arrival, systolic BP <90 or age-appropriate hypotension, 40 mL/kg fluid prior to arrival, respiratory distress or failure, and GCS ≤8. ↗
▶ Ep 2 · 53:00
host summary Richard Falcone summarizing a resource: Using the evidence-based 8-9 criteria resulted in an over-triage rate of 39% and under-triage rate of only 10%, with the break point being around 8 or 9 criteria where adding more criteria lowers under-triage but increases over-triage. ↗
▶ Ep 2 · 53:50
host summary Richard Falcone summarizing a resource: Brooke Lerner led a recent Journal of Trauma paper using the Delphi method to formally define high resources justifying trauma team activation, including ICU stay greater than 48 hours and other criteria from the initial multi-center work. ↗