# Traumatic Brain Injury — GCMD Library living collection

Everything in the library about traumatic brain injury — built automatically from dossiers that name it.

Updated: n/a · 4 episodes · 151 cited statements

## Episodes
### Acute Management
- [Traumatic Brain Injury](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942) — podcast · 14:04 · [machine version](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942.md)

### Case-Based Learning
- [Solid Organ Injury Management: Update Course 2017](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406) — video · 32:57 · [machine version](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406.md)

### In-Depth Reviews
- [Pediatric Trauma With Dr. Richard Falcone](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928) — podcast · 56:05 · [machine version](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928.md)
- [Traumatic Brain Injuries - Allison Bailey, Susan Beiting, Zach Paff, & Caitlin Chicoine - APP Conference 2026](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087) — video · 57:15 · [machine version](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087.md)

## Chapters
- [0:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=0) Case Presentation: Multi-System Trauma Initial Assessment (Ep 1)
- [7:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=420) Resuscitation Strategy and Imaging Decisions (Ep 1)
- [15:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=900) ATOMAC Guidelines and Operative Decision-Making (Ep 1)
- [25:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1500) Case Resolution and Key Teaching Points (Ep 1)
- [0:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=0) Introduction and Center Overview (Ep 2)
- [4:32](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=272) C-Spine Clearance Protocols (Ep 2)
- [15:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=910) C-Spine Clearance in Young Children (Ep 2)
- [18:48](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1128) Infant C-Spine Clearance (Ep 2)
- [20:48](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1248) Pancreatic Trauma Management (Ep 2)
- [27:44](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1664) Non-Accidental Trauma Screening (Ep 2)
- [33:09](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1989) Ophthalmologic Exams in Abuse Screening (Ep 2)
- [34:29](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2069) Blunt Abdominal Trauma Screening (Ep 2)
- [41:26](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2486) Angiography in Pediatric Solid Organ Injury (Ep 2)
- [43:49](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2629) Solid Organ Injury Management Updates (Ep 2)
- [48:28](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2908) Trauma Activation Criteria (Ep 2)
- [54:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3290) Closing and Conference Announcement (Ep 2)
- [0:11](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=11) Case presentation and initial management of pediatric TBI with epidural hematoma (Ep 3)
- [1:53](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=113) Management of intracranial hypertension and cerebral perfusion pressure (Ep 3)
- [6:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=390) Role of steroids in pediatric TBI (Ep 3)
- [6:52](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=412) Surgical options for refractory intracranial hypertension (Ep 3)
- [8:56](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=536) Imaging strategy: CT versus MRI in acute and subacute phases (Ep 3)
- [10:39](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=639) Recognition and management of sympathetic storming (Ep 3)
- [13:16](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=796) Clinical pearls summary (Ep 3)
- [0:00](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=0) Introduction and TBI Definition, Epidemiology, and Initial Assessment (Ep 4)
- [4:25](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=265) PECARN Head CT Rule and Emergency Department Case Scenarios (Ep 4)
- [11:31](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=691) PICU Management: Monro-Kellie Doctrine, ICP Monitoring, and Herniation Prevention (Ep 4)
- [20:25](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1225) Hyperosmolar Therapy, Sedation, Ventilation, and Tiered ICP Management (Ep 4)
- [28:03](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1683) Transition to Floor Care and Rehabilitation Readiness (Ep 4)
- [32:07](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1927) Inpatient Rehabilitation: Team, Disorders of Consciousness, and Paroxysmal Sympathetic Hyperactivity (Ep 4)
- [43:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2600) Cognitive and Behavioral Recovery, Discharge Planning, and Long-Term Outcomes (Ep 4)
- [52:49](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=3169) Audience Q&A: Primary Care Follow-Up, Adjusting Assessments for Baseline Deficits, and Insurance Barriers (Ep 4)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- A normal shock index is less than 1 or less than 0.9, with adjustments now available for pediatric patients — David (clinical) [Ep 1 · 7:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=420)
- The shock index allows clinicians not regularly seeing pediatric patients to assess for shock without knowing normalized blood pressure values for children — David (clinical) [Ep 1 · 7:30](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=450)
- 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 — David (clinical) [Ep 1 · 9:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=540)
- 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 — David (clinical) [Ep 1 · 13:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=780)
- FAST remains useful in unstable patients as a replacement for diagnostic peritoneal lavage (DPL) — David (opinion) [Ep 1 · 14:30](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=870)
- 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 — David (guideline) [Ep 1 · 20:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1200)
- 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' — David (clinical) [Ep 1 · 21:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1260)
- Hypotension due to solid organ injury is ominous, with significant risk of death and failure of non-operative management — David (clinical) [Ep 1 · 22:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1320)
- In younger children (not teenagers), blood pressure less than 50 mmHg is a really ominous sign with high risk of poor outcome — David (clinical) [Ep 1 · 22:30](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1350)
- Teenagers and adults can become hypotensive, respond to blood transfusion, and often be managed non-operatively, unlike younger children — David (clinical) [Ep 1 · 23:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1380)
- 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 — David (clinical) [Ep 1 · 25:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1500)
- 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 — David (guideline) [Ep 1 · 27:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1620)
- The ATOMAC guideline effectively guided care for 1,007 pediatric trauma patients in the prospective validation study — David (epidemiological) [Ep 1 · 28:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1680)
- Only about half of children in shock are hypotensive, meaning shock does not necessarily equal low blood pressure in pediatric patients — David (clinical) [Ep 1 · 28:30](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1710)
- 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 — David (guideline) [Ep 1 · 32:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1920)
- 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 — David (clinical) [Ep 1 · 32:30](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1950)
- Cincinnati Children's Hospital is a Level 1 pediatric trauma center verified since 1993, seeing approximately 2000 patients per year. — Richard Falcone (clinical) [Ep 2 · 3:08](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=188)
- At Cincinnati Children's, the ED physician serves as team leader for all traumas, chosen because they are present when the patient arrives. — Richard Falcone (clinical) [Ep 2 · 3:32](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=212)
- The ultimate risk of C-spine injury in pediatric trauma is actually pretty low. — Richard Falcone (epidemiological) [Ep 2 · 4:32](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=272)
- 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. — Richard Falcone (clinical) [Ep 2 · 4:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=290)
- 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. — Richard Falcone (clinical) [Ep 2 · 8:27](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=507)
- 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. — Richard Falcone (clinical) [Ep 2 · 9:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=590)
- The challenge in pancreatic trauma is determining whether there is a duct injury or not, which is the number one question and concern. — Richard Falcone (clinical) [Ep 2 · 21:35](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1295)
- 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. — Richard Falcone (clinical) [Ep 2 · 22:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1320)
- 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. — Richard Falcone (clinical) [Ep 2 · 23:20](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1400)
- 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. — Richard Falcone (clinical) [Ep 2 · 24:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1450)
- 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. — Richard Falcone (opinion) [Ep 2 · 25:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1500)
- 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. — Richard Falcone (clinical) [Ep 2 · 26:40](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1600)
- 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. — Richard Falcone (clinical) [Ep 2 · 27:28](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1648)
- 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. — Richard Falcone (clinical) [Ep 2 · 29:40](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1780)
- Abuse happens in all races and all socioeconomic bands, though economic stress does add some risk. — Richard Falcone (epidemiological) [Ep 2 · 30:20](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1820)
- 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. — Richard Falcone (clinical) [Ep 2 · 30:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1850)
- 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. — Richard Falcone (epidemiological) [Ep 2 · 31:40](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1900)
- A screening test that gives nearly a 50% positive rate of abuse is more productive than most screening tests we do for other things. — Richard Falcone (opinion) [Ep 2 · 32:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1950)
- 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. — Richard Falcone (clinical) [Ep 2 · 33:09](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1989)
- 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. — Richard Falcone (clinical) [Ep 2 · 33:23](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2003)
- 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. — Richard Falcone (clinical) [Ep 2 · 37:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2220)
- 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). — Richard Falcone (clinical) [Ep 2 · 37:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2270)
- 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. — Richard Falcone (opinion) [Ep 2 · 38:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2310)
- FAST is great for hypotensive patients to determine if they have blood in their abdomen, which is the classic reason FAST was developed. — Richard Falcone (clinical) [Ep 2 · 39:40](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2380)
- A negative FAST in a stable, healthy child may still miss injuries if you trust it too much. — Richard Falcone (clinical) [Ep 2 · 40:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2410)
- 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. — Richard Falcone (clinical) [Ep 2 · 41:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2510)
- 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. — Richard Falcone (clinical) [Ep 2 · 42:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2550)
- 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. — Richard Falcone (clinical) [Ep 2 · 43:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2590)
- 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. — Richard Falcone (clinical) [Ep 2 · 46:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2770)
- There is growing support for less lab draws, shorter length of stay, and less bed rest for solid organ injuries in children. — Richard Falcone (clinical) [Ep 2 · 48:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2890)
- 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. — Richard Falcone (clinical) [Ep 2 · 48:28](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2908)
- Grade 1 isolated spleen injuries may not even need hospital admission because they never get transfused and never have problems. — Richard Falcone (clinical) [Ep 2 · 49:10](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2950)
- For a patient with small epidural hematoma, immediate neurosurgical consultation is needed to determine if surgical evacuation is required. — Pramod Pulaamba (clinical) [Ep 3 · 1:08](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=68)
- Small epidurals may be managed with repeat CT in several hours or clinical observation for deterioration before operating. — Pramod Pulaamba (clinical) [Ep 3 · 1:25](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=85)
- ICP monitoring should be discussed with neurosurgeons for patients being managed for potential intracranial pressure issues. — Pramod Pulaamba (clinical) [Ep 3 · 1:40](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=100)
- Invasive blood pressure monitoring is needed for accurate blood pressure identification in patients with intracranial hypertension. — Pramod Pulaamba (clinical) [Ep 3 · 1:58](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=118)
- Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure. — Pramod Pulaamba (clinical) [Ep 3 · 2:10](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=130)
- ICP above 20 may require ongoing treatment and/or reevaluation with imaging. — Pramod Pulaamba (clinical) [Ep 3 · 2:40](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=160)
- Acute intracranial hypertension may first manifest as dilation of the ipsilateral pupil or progressive bradycardia with hypertension. — Pramod Pulaamba (clinical) [Ep 3 · 2:55](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=175)
- Acute ICP management includes raising the head of bed to improve venous drainage, providing oxygen, and bag valve masking. — Pramod Pulaamba (clinical) [Ep 3 · 3:15](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=195)
- Hyperventilation to PCO2 of around 35 helps vasoconstrict the brain and create space in acute ICP crisis. — Pramod Pulaamba (clinical) [Ep 3 · 3:35](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=215)
- If an ICP drain is present, opening it to evacuate fluid and reduce pressure is a first-line intervention. — Pramod Pulaamba (clinical) [Ep 3 · 3:55](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=235)
- 3% normal saline at 5 mL per kilogram will generally increase serum sodium by 3 to 5 mEq per liter. — Pramod Pulaamba (clinical) [Ep 3 · 4:10](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=250)
- 3% normal saline has an osmolarity limit of 360 millimoles compared to Mannitol's 320 millimoles. — Pramod Pulaamba (clinical) [Ep 3 · 4:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=270)
- Hypotension in the context of closed head injury is a very poor prognosticator and should be avoided at all costs. — Pramod Pulaamba (clinical) [Ep 3 · 4:45](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=285)
- In older children and teenagers, systolic blood pressure should be kept above 90 or 95; younger children should use age-appropriate norms. — Pramod Pulaamba (clinical) [Ep 3 · 5:00](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=300)
- Norepinephrine can be used to drive up blood pressure to maintain cerebral perfusion. — Pramod Pulaamba (clinical) [Ep 3 · 5:20](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=320)
- Mannitol's diuretic effect can be difficult to control and may lead to hypotension. — Pramod Pulaamba (clinical) [Ep 3 · 5:45](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=345)
- Mannitol's first effect within 15 to 20 minutes is changing blood vessel rheology to allow freer passage through cerebral circulation and improve oxygen delivery; the diuretic effect is secondary and occurs afterwards. — Pramod Pulaamba (clinical) [Ep 3 · 5:55](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=355)
- The dose of Mannitol is 0.5 g to 1 g per kilogram. — Pramod Pulaamba (clinical) [Ep 3 · 6:13](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=373)
- There is no role for steroids in pediatric traumatic brain injury. — Pramod Pulaamba (guideline) [Ep 3 · 6:33](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=393)
- Steroids are no longer considered effective therapy for suspected spinal cord injury and may cause detriment. — Pramod Pulaamba (guideline) [Ep 3 · 6:42](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=402)
- Decompressive craniectomy is an emerging option for patients with diffuse axonal injury and very difficult to control ICP where there is no true surgical lesion to decompress. — Pramod Pulaamba (clinical) [Ep 3 · 7:01](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=421)
- Patients with persistently elevated ICP above 20 with higher spikes will slowly deteriorate to the point where they are not salvageable. — Pramod Pulaamba (clinical) [Ep 3 · 7:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=450)
- In decompressive craniectomy, the bone is preserved and can be replaced after things settle down. — Pramod Pulaamba (clinical) [Ep 3 · 7:50](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=470)
- Major trauma centers across North America are using decompressive craniectomy more frequently. — Pramod Pulaamba (opinion) [Ep 3 · 8:40](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=520)
- CT scan is preferred in acute situations with very acute presentation of increased ICP because it provides the best information for determining need for OR or drain placement. — Pramod Pulaamba (clinical) [Ep 3 · 9:08](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=548)
- MRI is used after the first 48 hours once the patient is stable and ICP spikes are controlled, primarily as a prognosticator. — Pramod Pulaamba (clinical) [Ep 3 · 9:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=570)
- MRI provides useful information for counseling families and directing care plans when injury is very severe. — Pramod Pulaamba (clinical) [Ep 3 · 9:50](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=590)
- Repeat MRI in a week's time gives the true extent of injury and allows more meaningful discussions about level of disability. — Pramod Pulaamba (clinical) [Ep 3 · 10:05](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=605)
- CT head scan can be completed in 5 minutes versus 20-30 minutes for MRI, making CT preferable for critical patients. — Pramod Pulaamba (clinical) [Ep 3 · 10:17](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=617)
- Sympathetic storming is thought to occur because of an imbalance of the sympathetic and parasympathetic nervous systems as a result of head injury. — Pramod Pulaamba (clinical) [Ep 3 · 10:55](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=655)
- Untreated sympathetic storming can lead to secondary brain injury or potentiate ongoing injury. — Pramod Pulaamba (clinical) [Ep 3 · 11:15](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=675)
- Hyperventilation during sympathetic storming leads to vasoconstriction which could lead to cerebral hypoxia and further cellular injury. — Pramod Pulaamba (clinical) [Ep 3 · 11:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=690)
- Hypertension during sympathetic storming could lead to hemorrhage within areas of the brain. — Pramod Pulaamba (clinical) [Ep 3 · 11:50](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=710)
- Arrhythmias during sympathetic storming can lead to hemodynamic instability and hypoperfusion, worsening head injury. — Pramod Pulaamba (clinical) [Ep 3 · 12:05](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=725)
- Neurogenic pulmonary edema is sometimes common in patients with sympathetic storming, leading to hypoxia and difficult ventilation. — Pramod Pulaamba (clinical) [Ep 3 · 12:20](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=740)
- The cornerstone of sympathetic storming treatment is sedation and pain control, usually accomplished with narcotics and/or benzodiazepines as first-line medications. — Pramod Pulaamba (clinical) [Ep 3 · 12:40](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=760)
- Bromocriptine acts on the hypothalamus to help reduce hyperthermia, diaphoresis, and blood pressure in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 12:55](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=775)
- Oxycodone has been used for its longer-acting effect for pain control in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Propranolol can help control arrhythmias and lower blood pressure in sympathetic storming. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Clonidine is an alpha-2 agonist that can reduce levels of catecholamines throughout the body and reduce ongoing sympathetic storm. — Pramod Pulaamba (clinical) [Ep 3 · 13:08](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=788)
- Traumatic brain injury (TBI) is a disruption of normal brain function caused by an external force, either a blow to the head or a penetrating injury that directly damages brain tissue. — Alison Bailey (clinical) [Ep 4 · 1:06](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=66)
- Falls account for approximately 50% of pediatric TBIs in the United States, making them the most common mechanism. — Alison Bailey (epidemiological) [Ep 4 · 2:12](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=132)
- Being struck in the head by an object accounts for about 28% of pediatric TBI cases. — Alison Bailey (epidemiological) [Ep 4 · 2:25](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=145)
- Motor vehicle crashes are the leading cause of TBI-related death in children older than 5 years. — Alison Bailey (epidemiological) [Ep 4 · 2:35](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=155)
- Homicide is the leading cause of TBI-related death in children ages 4 and younger. — Alison Bailey (epidemiological) [Ep 4 · 2:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=165)
- The Glasgow Coma Scale (GCS) is a standardized assessment that objectively evaluates a patient's level of consciousness by examining eye-opening, verbal response, and motor response, producing a total score from 3 to 15. — Alison Bailey (clinical) [Ep 4 · 3:05](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=185)
- Mild TBI corresponds to a GCS score of 13 to 15, moderate TBI to 9 to 12, and severe TBI to a score of 8 or less. — Alison Bailey (clinical) [Ep 4 · 3:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=225)
- Patients with moderate TBI typically require neuroimaging and hospital admission for monitoring. — Alison Bailey (clinical) [Ep 4 · 4:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=250)
- Patients with severe TBI often cannot protect their airway and require intensive care monitoring and neurosurgical evaluation. — Alison Bailey (clinical) [Ep 4 · 4:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=260)
- The PECARN head CT rule is a validated tool designed to identify children at very low risk of clinically important brain injuries after minor blunt head trauma, helping to avoid unnecessary CT scans and radiation exposure. — Susie Biding (guideline) [Ep 4 · 4:55](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=295)
- For children younger than 2 and those 2 years or older, a CT scan is recommended if the child has altered mental status, a GCS less than 15, or signs of a skull fracture. — Susie Biding (guideline) [Ep 4 · 5:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=320)
- If no high-risk PECARN criteria are present, the rule guides weighing other factors such as loss of consciousness, vomiting, severe headache, or severe mechanism of injury to decide between observation or CT imaging. — Susie Biding (guideline) [Ep 4 · 5:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=340)
- Given a declining neurologic status and GCS below 8, the immediate priority is protecting the airway to prevent hypoxia and hypoventilation; there is a saying 'GCS less than 8, intubate.' — Susie Biding (clinical) [Ep 4 · 10:50](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=650)
- The Monro-Kelley doctrine states that the skull is a fixed rigid space containing brain, blood, and CSF; if any one of these increases, pressure rises. — Zach Paff (clinical) [Ep 4 · 12:05](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=725)
- The body can compensate for increased intracranial volume by pushing out CSF and reducing venous blood flow, but there are limitations to this compensation. — Zach Paff (clinical) [Ep 4 · 12:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=750)
- Tonsillar herniation, where the cerebral tonsils are pushed downward through the base of the skull, results in respiratory arrest and death. — Zach Paff (clinical) [Ep 4 · 13:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=790)
- Early signs of herniation include the Cushing's triad (hypertension and bradycardia) and posturing. — Zach Paff (clinical) [Ep 4 · 13:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=810)
- Emergency interventions for impending herniation include hyperventilation to lower CO₂, 100% oxygen, intubation if not already done, 3% saline, and opening an external ventricular drain (EVD) if present to drain CSF. — Zach Paff (clinical) [Ep 4 · 13:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=825)
- PICU goals for TBI patients include maintaining normal oxygen levels to prevent tissue hypoxia, normal PaCO₂ by titrating the ventilator, ICP less than 20 mmHg, and cerebral perfusion pressure (CPP) of 40 to 60 mmHg based on age. — Zach Paff (clinical) [Ep 4 · 15:50](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=950)
- Cerebral perfusion pressure (CPP) is calculated as mean arterial pressure (MAP) minus intracranial pressure (ICP). — Zach Paff (clinical) [Ep 4 · 17:23](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1043)
- CPP represents the driving pressure for cerebral blood flow, while ICP provides resistance to that driving pressure. — Zach Paff (clinical) [Ep 4 · 17:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1060)
- MAP is augmented by giving fluid, volume, and inotropes; ICP is reduced by giving sedation, paralytics, 3% saline, and ensuring the patient is positioned neutral and midline to avoid impeding venous return. — Zach Paff (clinical) [Ep 4 · 17:55](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1075)
- Immediate interventions for elevated ICP include ensuring the head is midline and administering a sedative. — Susie Biding (clinical) [Ep 4 · 20:00](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1200)
- Hyperosmolar therapy with 3% saline (approximately 3 times the sodium concentration of normal saline) is given as a 4 mL/kg bolus or continuous infusion, targeting serum osmolarity of 275 to 295 mOsm/L. — Zach Paff (clinical) [Ep 4 · 20:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1240)
- 3% saline has benefits over mannitol including less diuretic effect, steadier ICP control, and better tolerance of higher osmolarities. — Zach Paff (clinical) [Ep 4 · 21:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1270)
- If osmolarity is driven too high (above 360 mOsm/L), complications include thrombosis and stroke. — Zach Paff (clinical) [Ep 4 · 21:25](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1285)
- Sodium is the most important contributor to serum osmolarity, calculated as 2 times the sodium plus BUN divided by 2.8 plus glucose divided by 18. — Zach Paff (clinical) [Ep 4 · 21:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1300)
- Hyperosmolar therapy works by creating an osmotic gradient that draws water out of brain cells into the extracellular space, shrinking the brain and decreasing ICP. — Zach Paff (clinical) [Ep 4 · 22:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1340)
- Sedation is the backbone of PICU management for TBI patients; it prevents ICP spikes by relaxing the patient, decreases metabolic demand and brain activity, reduces oxygen demand, and decreases cerebral blood flow. — Zach Paff (clinical) [Ep 4 · 22:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1365)
- Neuromuscular blockade prevents shivering during temperature control, stops posturing or storming, and reduces metabolic demand and oxygen consumption; it also allows better venous drainage by relaxing the patient. — Zach Paff (clinical) [Ep 4 · 23:15](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1395)
- CO₂ regulates cerebral blood flow: high CO₂ causes vasodilation and increased cerebral blood volume, raising ICP; low CO₂ causes vasoconstriction and decreased blood flow. — Zach Paff (clinical) [Ep 4 · 23:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1425)
- Target PaCO₂ is tightly controlled at 35 to 45 mmHg; brief hyperventilation can be used for impending herniation or very high ICP spikes, but prolonged hyperventilation risks tissue ischemia. — Zach Paff (clinical) [Ep 4 · 24:05](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1445)
- High positive end-expiratory pressure (PEEP) can impede venous drainage and raise ICP, so PEEP must be balanced to keep lungs open without excessive pressure. — Zach Paff (clinical) [Ep 4 · 24:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1485)
- Barbiturate coma (using pentobarbital) massively reduces metabolic demand and cerebral activity, decreasing cerebral blood flow and ICP; the brain is kept at rest while on continuous EEG monitoring. — Zach Paff (clinical) [Ep 4 · 25:15](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1515)
- Barbiturates have significant side effects including severe hypotension requiring inotropes, direct cardiac suppression, and immune suppression with prolonged use, increasing sepsis risk. — Zach Paff (clinical) [Ep 4 · 25:45](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1545)
- If medical management fails, decompressive craniectomy removes part of the skull bone, allowing the brain to expand outward and reducing ICP by manipulating the Monro-Kelley doctrine. — Zach Paff (clinical) [Ep 4 · 26:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1600)
- The trauma team organizes care conferences with the family, ICU team, rehab team, neurosurgery, neurology, therapists, and nurses to ensure shared understanding of injuries, management, and goals. — Susie Biding (clinical) [Ep 4 · 28:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1700)
- On the trauma step-down floor, focus shifts from stabilization to recovery and rehabilitation, including continuing therapy services (PT, OT, speech), normalizing medical care by transitioning to oral medications and regular diet, and providing family support. — Susie Biding (clinical) [Ep 4 · 30:50](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1850)
- To qualify for inpatient rehab, children must require at least 2 of the 3 primary therapy disciplines (PT, OT, speech) and tolerate at least 3 hours of therapy per day on at least 5 days per week. — Caitlin Chicoine (guideline) [Ep 4 · 32:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1950)
- To be ready for inpatient rehab, patients need to be fairly medically stable: afebrile for at least 24 hours, tolerating full enteral nutrition, pain controlled on oral medications, and having a stable plan for respiratory support. — Caitlin Chicoine (clinical) [Ep 4 · 33:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=1990)
- Inpatient rehab is considered a separate hospital stay from an insurance standpoint and requires prior authorization. — Caitlin Chicoine (clinical) [Ep 4 · 34:00](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2040)
- The inpatient rehab team includes PMNR physicians, nursing, therapeutic recreation, music therapy, integrative care, child life, school team, psychology, nutrition, social work, and care manager. — Caitlin Chicoine (clinical) [Ep 4 · 34:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2080)
- An evaluation and planning meeting is held within a few days of admission, where the team reviews the patient's case and current status, then the family joins to discuss plans, answer questions, and set a tentative discharge date. — Caitlin Chicoine (clinical) [Ep 4 · 35:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2130)
- Disorder of consciousness (DOC) is an alteration in level of awareness of self and environment, divided into coma (unresponsive, no sleep-wake cycles, eyes closed), unresponsive wakefulness (unresponsive but with sleep-wake cycles and eyes open), and minimally conscious (inconsistent but clear responses to environment such as visual tracking or following commands). — Caitlin Chicoine (clinical) [Ep 4 · 36:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2200)
- Patients are considered to have emerged from disorder of consciousness when they demonstrate accurate yes/no responses and functional object use (e.g., using a comb correctly). — Caitlin Chicoine (clinical) [Ep 4 · 37:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2250)
- Patients with disorder of consciousness are appropriate candidates for inpatient rehab, though their engagement in therapies will look different. — Caitlin Chicoine (clinical) [Ep 4 · 38:00](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2280)
- Goals for patients with DOC include stimulating wakefulness by weaning sedating medications, optimizing nighttime sleep, providing daytime stimulation through therapeutic activities, and using dopaminergic medications. — Caitlin Chicoine (clinical) [Ep 4 · 38:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2310)
- The Coma Recovery Scale–Revised is used to monitor subtle changes in responsiveness as medications are adjusted and therapy progresses. — Caitlin Chicoine (clinical) [Ep 4 · 39:05](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2345)
- Paroxysmal sympathetic hyperactivity (PSH or 'storming') is a dysautonomia representing excessive sympathetic nervous system activity due to loss of normal inhibitory influences from the brain, causing non-noxious stimuli to be perceived as noxious. — Caitlin Chicoine (clinical) [Ep 4 · 40:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2420)
- PSH presents as spells of increased sympathetic activity: high heart rate, high blood pressure, high respiratory rate, increased temperature, and posturing. — Caitlin Chicoine (clinical) [Ep 4 · 40:55](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2455)
- PSH is a diagnosis of exclusion; other medical problems such as infection, pulmonary embolism, or appropriate pain response must be ruled out. — Caitlin Chicoine (clinical) [Ep 4 · 41:15](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2475)
- First-line treatment for PSH is environmental interventions (calm room, repositioning, changing soiled clothes); medications such as propranolol, clonidine, benzodiazepines, or gabapentin may be used as needed or scheduled, but many are sedating. — Caitlin Chicoine (clinical) [Ep 4 · 41:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2490)
- The Ranchos Los Amigos scale describes stages of cognitive recovery; level 4 (confused and agitated) is common and temporary, typically occurring before emergence from post-traumatic amnesia when patients are not yet forming new memories. — Caitlin Chicoine (clinical) [Ep 4 · 42:40](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2560)
- For agitation at Ranchos level 4, environmental interventions are preferred: avoiding overstimulation, turning down lights, limiting visitors, and minimizing tubes and lines when possible. — Caitlin Chicoine (clinical) [Ep 4 · 43:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2610)
- At Ranchos level 5, patients remain confused and no longer agitated but are not yet appropriate; they have impaired memory and may confabulate, which can be distressing to parents. — Caitlin Chicoine (clinical) [Ep 4 · 44:00](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2640)
- More than 50% of children with traumatic brain injuries develop novel psychiatric disorders such as ADHD or anxiety after their injury. — Caitlin Chicoine (epidemiological) [Ep 4 · 45:50](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2750)
- Common impairments after TBI include motor deficits (weakness, increased tone, impaired coordination and balance), sensory deficits (loss of smell, visual deficits, hearing loss), dysphagia, behavior issues, and cognitive/communication difficulties (aphasia, attention, memory, processing speed, executive functioning problems). — Caitlin Chicoine (clinical) [Ep 4 · 46:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2770)
- Crucial players in transition home include nurses (provide education), social work (connect to community resources, help with transportation and home modifications), and care manager (orders equipment and supplies, ensures smooth transition to outpatient therapy). — Caitlin Chicoine (clinical) [Ep 4 · 47:30](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2850)
- For complex patients, a 24-hour stay simulates being at home while still admitted to rehab: the family initiates all care, gives tube feeds, and asks for medications when due, with backup support from the team. — Caitlin Chicoine (clinical) [Ep 4 · 48:15](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2895)
- Patients typically complete neuropsychological testing while on rehab to understand cognitive function and inform their school plan; the school liaison communicates directly with the school about current needs and facilitates transition. — Caitlin Chicoine (clinical) [Ep 4 · 48:55](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=2935)
- Risk factors associated with worse outcome after severe TBI include younger age, lower GCS motor score at presentation, unreactive pupils, longer duration of coma, and MRI findings such as larger contusion volume, ischemic changes, or brainstem lesions. — Caitlin Chicoine (clinical) [Ep 4 · 50:20](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=3020)
- Recovery from severe traumatic brain injury is measured in months to years, not weeks or days; inpatient rehab is only the initial burst of intensive therapy. — Caitlin Chicoine (clinical) [Ep 4 · 51:10](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=3070)
- Some patients do not emerge from disorder of consciousness while in rehab but emerge later and may return to inpatient rehab for additional support when they are in a different place to engage with therapies. — Caitlin Chicoine (clinical) [Ep 4 · 51:35](https://team.globalcastmd.com/watch/traumatic-brain-injuries-allison-bailey-susan-beiting-zach-paff-caitlin-chicoine-app-conference-2026-12087?t=3095)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- FAST has lost appeal in stable pediatric trauma patients because it misses too many injuries, as shown by the PECARN Group study — David summarizing the discussion [Ep 1 · 14:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=840)
- Adult studies show that ideal blood pressure after head injury is much higher than previously thought, with blood pressure of 150-160 mmHg associated with better outcomes than 90-120 mmHg, suggesting Cushing's reflex may be protective — David summarizing the discussion [Ep 1 · 24:00](https://team.globalcastmd.com/watch/solid-organ-injury-management-update-course-2017-406?t=1440)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 6:04](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=364)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 7:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=420)
- CT or MRI of the C-spine should only be considered for patients with abnormal neurologic exam findings. — Richard Falcone summarizing a resource [Ep 2 · 7:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=450)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 16:07](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=967)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 17:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1050)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 18:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1080)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 18:30](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1110)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 28:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=1730)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 35:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2100)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 36:24](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2184)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 39:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2340)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 44:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2640)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 44:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2690)
- By shortening bed rest for solid organ injuries, you can cut down significantly on length of stay without having readmissions or complications. — Richard Falcone summarizing a resource [Ep 2 · 45:40](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2740)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 46:38](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2798)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 47:20](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=2840)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 50:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3000)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 50:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3050)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 52:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3120)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 53:00](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3180)
- 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. — Richard Falcone summarizing a resource [Ep 2 · 53:50](https://team.globalcastmd.com/watch/pediatric-trauma-with-dr-richard-falcone-928?t=3230)
- Traumatic brain injury caused over 837,000 visits, hospitalizations, and deaths in children in 2014. — The host summarizing a resource [Ep 3 · 0:11](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=11)
- Most guidelines suggest keeping CPP greater than 45 as the minimal acceptable, sometimes 55 in children. — Pramod Pulaamba summarizing a resource [Ep 3 · 2:25](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=145)
- Based on the most recent guidelines in Pediatric Critical Care Medicine, there is no evidence that 3% saline is better than Mannitol or vice versa. — Pramod Pulaamba summarizing a resource [Ep 3 · 5:30](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=330)
- Based on the 3rd iteration of Management of Traumatic Brain Injury in Children published in Pediatric Critical Care Medicine, there is still no clear consensus that decompressive craniectomy improves outcomes. — Pramod Pulaamba summarizing a resource [Ep 3 · 8:15](https://team.globalcastmd.com/watch/traumatic-brain-injury-1942?t=495)

## Changelog
- Sep 25: 1 item added automatically
- Sep 16: 3 items added automatically

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