Okay, thank you, everyone, for your patience. We are ready to start, and I want to just welcome you now to our webinar today called The Management of Pediatric Intracranial Gunshot Wounds and Factors Associated with Survival. We have Dr. Michael DeCypher here, and I'm just going to give a very brief bio and let him get started since we're running a little bit late, but we're glad he made it. So Dr. Michael DeCypher completed his neurosurgical residency in Memphis with Sons Murphy Clinic and the University of Tennessee Department of Neurosurgery, where he is currently an assistant professor. He has completed fellowships in minimally invasive neurosurgical oncology and complex endoscopy with Dr. Charlie Tao in Sydney, Australia, and pediatric neurosurgery with Dr. Rick Lube at Le Bonheur Children's Hospital, St. Jude Children's Research Hospital in Memphis. As a pediatric and adult neurosurgeon at Sons Murphy, Dr. DeCypher specializes in minimally invasive neurosurgery, brain tumors, trauma, CFF shunts, carie malformation, cranial endoscopy, aneurysms, vascular malformations, peripheral nerve surgery, disc herniation, adult generative spinal stenosis, and pediatric scoliosis. So that was a mouthful. So thank you, Dr. DeCypher. I'm just going to turn it over so that we can get started. It looks like someone says that they can't hear me. But why don't you just get started for us? Okay, sure. No problem. Well, thank you for your patience. I apologize for running late. Traffic was really awful today, of course, when I needed to get somewhere. But as Christine said, today, I'm Dr. Mike DeCypher from Memphis, Tennessee. And today, we're going to discuss the management of pediatric intracranial gunshot wounds and some factors associated with survival. So the objectives today that we'll discuss will be, first, review the results of our large retrospective cohort of children with intracranial gunshot wounds here in Memphis. We'll also identify some clinical and radiological factors that are predictive of poor outcome in children who have sustained a gunshot wound to the head. And then we'll discuss how we here in Memphis manage gunshots to the head, both medically and surgically, and some pointers that both physicians and nurses can utilize that we have found helpful. I have no financial disclosures today. So as a bit of a background, gunshots to the head, obviously, are due to firearms, most commonly in the United States, due to low-velocity handguns. And as many of the doctors at U.S. trauma centers can attest, unfortunately, it's becoming more common all the time. Over the years from 2004 to 2010, there were about 1.4 pediatric deaths per 100,000 population over the entire U.S. And injury from a firearm is the fifth leading cause of hospitalization due to violent means for children in 2015. So, obviously, gunshot wounds to the head are associated with significant morbidity and mortality. The best numbers currently we can come up with, based on the literature, are about 50 to 90% in adults and about 20 to 60% mortality in children. And you can see, just looking at those numbers, that the game is different with kids to some degree, and children present a lot of different challenges for all of the physicians involved from the ER to the surgeons to the ICU, et cetera. And these all are clearly deciding on what to do and how to do it, but also being able to talk to families and give them some information on the front end and on the back end sometimes about, you know, some prognosis and should we even do anything. And that's, quite frankly, the most important question to answer on the front end when the child hits the door in the emergency room is should we do anything. So, in the state of Tennessee, my home state, the annual death rate from intracranial gunshot wounds is about nine deaths per 100,000 population for all ages, both adults and children. The number of deaths in the state of Tennessee was highest in Shelby County, which is where Memphis is located, where 561 people died from a gunshot wound to the head over the years of 2004 to 2010. Currently, the annual death rate for gunshot wounds in children in the state of Tennessee is about 1.6 per 100,000 population. Again, highest in our county, which is Shelby County. So, in general, we always say we should exercise caution when you try to extrapolate adult literature to the pediatric population for just about anything, but especially for trauma and neurotrauma specifically. As a general rule for any kind of traumatic brain injury, children typically have overall lower morbidity and a greater propensity for neurological recovery than adults. So, that also adds another level of difficulty when you're trying to give the family some prognostic information moving forward because kids typically do better and they typically recover better. So, with this in mind, you may notice that the treatment paradigm for kids with a gunshot are different from center to center to center based sometimes on their own experience more so than any literature can provide. That was the impetus, ultimately, for us to look back at our own data here in Memphis because we have such a high volume, unfortunately, of children who suffer gunshots to the head. So, we look back at our own patients at Le Bonheur and the Elvis Presley Memorial Trauma Center, which is just next door, who also get some pediatrics, and we identified 71 patients with an isolated penetrating gunshot wound to the head from birth to 18 years of age from the years of 1996 to 2012. All of the patients were evaluated at a level one trauma center, either at Elvis Presley Memorial or at Le Bonheur Children's Medical Center. We cover both centers, my neurosurgical group does, so we were available to evaluate all the patients as they arrive. So, these are just some of the demographics we noticed of the children, and you can see that 80% of the children were male, and as far as race is concerned, it's almost equal to African American and Caucasian, less so Hispanic children. You can see below that on the table the age ranges in years where it's more rare to find a young child, very young child, or a baby with a gunshot to the head, but it's much more common, at least in our experience, to find a 13 to 18-year-old adolescent teenager with a gunshot to the head. Interestingly, on the right side of the slide, you can see the etiologies that we were able to ascertain from these incidents, and by far, you know, 35% of these children were an assault, actually. That was followed by a self-inflicted gunshot accidental, so this could be a child finding a handgun unfortunately loaded and safety off in the house or other area. There were actually 14% suicides, which is somewhat surprising or maybe surprising to some people. Innocent bystander at the bottom there was about 18%. That could be a victim of a drive-by shooting or a victim sitting in a car shot, you know, as a bystander during another assault. Accidental gunshot by other. Unfortunately, we see some incidents where a sibling accidentally shoots another sibling or sometimes even a family member accidentally shoots a child. Those were less common in our series. So the overall mortality rate in our series was about 48%, so 34 of these 71 children did not survive their injury. We performed a surgical intervention of some sort in 55% of the patients or 39 patients. From a post-op complication standpoint, we had five wound infections requiring a re-operation and we had three cerebrospinal fluid leaks that required some sort of intervention to repair. Ultimately, 22 patients were discharged home and 15 patients were discharged to a rehab facility. Among our survivors, the 37 patients, the mean mechanical ventilation time was about 11 to 12 days. Now, the range was quite large as you can see from no intubation to 40 plus days of mechanical intubation. As far as stay in the ICU, the average was 12 days and the overall hospital stay average was about 15 days with, of course, quite a wide range depending on the severity of the injury and the number of interventions that were undertaken. So now we're going to look at the admission GCS score for both the deceased and the survivors. As you can see, and it probably wouldn't surprise many people, is that most of the deceased children who arrived at the emergency room were a GCS3 or a GCS4. Actually, there was a child who was a GCS15 who also did not survive his injury, but clearly there is a skew towards the lower end of the GCS scale. As you would also expect, on the survival side, there were a very high number of children who presented with a very high GCS, a GCS15 or a GCS14. There were actually, as you can see on the left side of the screen, some children in the lower end of the GCS range that did survive. I'll talk about this a little bit later as far as using GCS score on the front end and some obstacles that that can present, but suffice to say at this point that by looking at these slides, you can tell that children who arrive who are GCS3 are fighting an uphill battle, and vice versa, children who arrive with a GCS15 have a good chance of survival. One of the physical exam findings that we found most useful in all of our series was the initial pupillary exam. As you can see here, it's pretty clear that a child who presents with bilateral fixed and dilated pupils in our series, 100% mortality associated with that finding. Bilateral and fixed, which means one side or the other, of course, actually was about 50-50 if you look at our numbers. Single-blown pupil would not stop us necessarily from intervening based on this. Of course, equal and reactive, the vast majority of children survived who present with that pupil exam. Deep nuclear injury, now this is a finding on imaging, and you can see that when the deep nuclei of the brain, meaning the thalamus and the basal ganglia, when those structures are involved in the deep gray matter centers of the brain, high mortality is associated. You can see that when the deep nuclear structures of the brain were involved, we found a 97% mortality rate in all comers. When they're not involved, again, it's about 60% survival rate or 70% survival rate when the deep nuclei are not involved on imaging. Midline shift is another one that we found that can sometimes be helpful and other times not. When midline shift is present, however, 80% of the children who encountered or were found to have this on imaging did not survive their injury. Of course, it's about 50-50 on the other side when midline shift is not found on imaging. When it comes to the number of lobes involved, we used a certain method to calculate the number of brain lobes involved, especially when the gunshot involved both hemispheres potentially or sort of a tangential shot or trajectory path that involved several lobes. As you would expect, the more lobes that are involved in the brain injury, the higher the mortality. You can see that children who had four lobe injury had 100% mortality rate, whereas only a single lobe, such as the frontal lobe or just the temporal lobe or maybe just the parietal lobe, fared much better and 90% of those children survived their injury. Another finding on imaging that we found to be very useful when it comes to prognostication and associated with mortality was a transventricular trajectory, meaning that the bullet crossed through the ventricles from either side. When we found this on imaging, there was about a 97% mortality rate. This was one of the most useful findings on imaging that we utilized. When it's absent, as you can see, it's about 50-50. Here's an example of a scan on a child. This was a teenager who presented to the emergency room. Here are the findings, as you can see on the imaging. There were bilateral involvements, so the entrance wound, as you can see, is on the right side and it tracks over to the left side. You can see on the far upper image that the bullet is lodged on the other side of the bone in the scalp. There's also a transventricular trajectory. You can see there's a lot of blood in the ventricles on these pictures. There's also some deep nuclear injury involved, meaning that the basal ganglia and part of the thalamus was injured in this incident. There's also what we consider three-lobe injury, meaning two frontal lobes and a temporal lobe. This child presented actually with a GCS of 6 and intubated in our emergency department. Given the exam at the time, we did choose to take this child for emergent surgery and ended up having to have bilateral craniectomies due to the bilateral nature of the injury. Ultimately, the child required bilateral titanium cranioplasties because the bone was sort of unusable at the end of the day. We did have to do a revision for a CSF leak because there was a massive amount of brain and dural injury associated with this injury. Ultimately, the Glasgow outcome scale was 3 at two years from the injury. This is what we consider not a favorable outcome, a Glasgow outcome scale score of 3. We'll talk about that. I have a slide to show you that later. This is one of those children where we went to heroic measures. It saved their life, but ultimately their long-term recovery was maybe not as good. Here is the Glasgow outcome scale. You can see that on the left figure, it explains the Glasgow outcome scale. The score of 1 is death, so the person did not survive. A Glasgow outcome scale of 2 is a persistent vegetative state. A Glasgow outcome scale of 3 means severe disability and dependent upon care from other people for just about everything. We would consider 2 or 3 in a survivor as to be a non-favorable outcome. A Glasgow outcome scale score of 4 or 5 shows independent with minor disability. In the case of a 4, a Glasgow outcome scale of 5 is the best. That person would be considered normal with very minimal disability. On this figure, you can see that we have shown the Glasgow outcome scale of all the patients in this series. The surgical patients are in gray and all patients are in the black bars. You can see that we did have a decent proportion that were in the 4 and 5 range. This is actually 81% of our series had a Glasgow outcome scale of 4 or 5, which we would consider a good outcome long-term. On the right side, we broke down the Glasgow outcome scale in a 2 or 3 or 4 or 5, as you can see in the columns. The take-home from this figure on the right side is that on a lot of these findings, specifically bilateral fixed pupils, deep nuclear injury, injury to greater than three lobes, transventricular trajectory, bi-hemispheric injury, a lot of the things we noticed, there were more children in the Glasgow outcome scale 2 or 3. Not only did those things portend higher mortality, but the morbidity was more significant also, so that if they did survive, they were considered either in a persistent vegetative state or dependent with a severe disability. The next slide shows the overall emergency room GCS score of all children in this series. On the right side, it shows the Glasgow outcome scale plotted as a function of the EDGCS score. You can see that the trend, as you would expect, is the higher the GCS on arrival to the emergency room, the greater the chances of having a Glasgow outcome scale of 4 or 5. Conversely, if you arrive to the ER with a GCS of 3, the chances of you having a good Glasgow outcome scale score long-term is not very good. Here are our statistical numbers when we looked at clinical and radiological data when it comes to survival mortality. I put red arrows to all of the significant findings when we did a bivariate testing. I've also listed them on the right side of the slide. Basically, the predictors of mortality, which were significant based on our statistical tests, were, number one, bilateral fixed and dilated pupils, followed by deep nuclear injury on imaging and transventricular trajectory on imaging, bilateral or bi-hemispheric injury, and also injury to more than three or more lobes, I should say. We also found a significant association between low blood pressure and anemia or hematocrit less than 30%. These findings were probably more related to under-resuscitation necessarily than a standalone finding. We don't use those in isolation as such, and I'll talk about that a little bit later. Also, a GCS score of less than 5 and a base deficit of greater than 5 were also found to be significantly associated with mortality. Interestingly, the age of the patient, when we converted that to a categorical variable, was actually not predictive of survival. Just because a child is younger or older does not actually give them a better or worse prognosis. Any person under the age of 18 in our series had about an equal chance of survival based alone on their imaging and clinical findings. In conclusion of our study, it does demonstrate a significant association between GCS and mortality, but we really don't recommend using a strict GCS cutoff alone because of its inaccuracy. As many of the ER nurses and physicians and everyone is probably familiar with, when a child arrives in the emergency room who's been intubated in the field, they've probably been sedated and maybe paralyzed. It's hard to get a good exam on that child. You have to hold the sedatives and the paralytics and try to get an exam. We don't typically say, just because you're a GCS3, there's nothing to do. Pupil reactivity, as I mentioned before, was very predictive. If a child comes in with a gunshot to the head that's a GCS3, and they're fixed and dilated bilaterally, we usually say there's really nothing to do here, that this is a non-survivable injury. When it comes to imaging findings, as I showed you previously, deep nuclear injury was highly associated with mortality, as well as involvement of three or more lobes of the brain, as well with transventricular trajectory. These are our strongest findings when it comes to imaging. Our transventricular trajectory, three or more lobe injury, deep nuclear injury. Midline shift was actually not really that predictive of overall mortality, so midline shift in and of itself does not necessarily mean that the child's not going to survive. But midline shift, in addition to those other findings that I discussed, would also lead us towards maybe not doing something based on exam findings. In our series, 52% of children with a gunshot wound to the head survived with aggressive surgical and medical care, and 81% of survivors had a favorable outcome, meaning a Glasgow Outcome Scale of 4 or 5, which we feel is pretty good. There's a lot of kids with gunshots to the head who arrive, and with aggressive therapy we got 80% with a favorable outcome from a potentially catastrophic injury. However, none of the factors, with the exception of bilateral fixed and dilated pupils, should be used alone to determine prognosis and treatment. That's sort of what I was saying maybe a slide ago, is that we sort of take the whole picture together and make a decision moving forward. Like I mentioned, we use the GCS and the pupil score, and we look at the imaging. When we start finding several of those significant variables when it comes to exam and imaging, that's where we say, you know what, maybe we shouldn't proceed as aggressively as we would in other children. So now, that being said, with our data presented, now I'll kind of go through how we sort of manage gunshots to the head at Le Bonheur in Memphis. We tend to perform surgery on all adequately resuscitated patients who we believe could survive the injury. Adequately resuscitated means, you know, if a child's actively coding in the ER, I'm not going to take them to the operating room. That's not going to go well. But if the child's stable from a cardiovascular standpoint, and has some decent exam findings, and we don't see a lot of those findings that I mentioned on imaging, then we definitely take those children to the operating room in an emergent fashion. So we don't tend to sit on these. And something else that we do here that some places otherwise don't is that, in our philosophy, we don't wait around to gather ICP data before we decide to take the child to the operating room or not. We use ICP data post-operatively, but pre-op ICP in our regard is not that useful. It's probably going to be high. If you put an ICP monitor or a ventric in a child who's got a gunshot to the head, more often than not, it's going to be high. So, in Memphis, if a child comes to the ER and we decide to do something, we're not going to do any kind of upfront ICP monitoring. We're just going to take them to the OR and do surgery. And the surgery that we take them to the OR for can be something as simple as a wound treatment and maybe a small craniotomy if it's a graze-type injury or something that's not that deep. Or it could be a full-blown decompressive craniectomy, enduroplasty, sometimes bilateral, in the example I showed earlier. So it could be a very big surgery or it might be a relatively small surgery, depending on the severity of the injury. And also, if a child makes it through the initial surgery but is still having ICP problems in the ICU post-op, we will take them back and do more surgery if it's not responsive to maximum medical management. So, just because we do surgery on the front end doesn't mean we're going to not take them back again necessarily. So, for any surgeons in the room or people who take care of these in the operating room, these are some of our tenets that we sort of live by when it comes to neurosurgery. One of the things that a lot of my partners have definitely found out the hard way over the years is that we don't chase deep fragments. If you've got deep metal or bone fragments in the brain, going after those and trying to fish them out usually leads to a lot more bleeding and a lot more brain injury. Sometimes it's best to just leave those alone and clean out the surface stuff, stop the bleeding and get out of dodge. Another thing that we've noticed is the bifrontal craniectomy can be dangerous. So, a child who say comes in with only bifrontal injuries and a very anterior gunshot wound, a lot of times we don't advocate doing a bifrontal craniectomy on the front end because of the post-op swelling. A bifrontal craniectomy is not going to get you the amount of room that a hemicraniectomy necessarily would. So, if a child comes in with a bifrontal gunshot wound, most often we will take them back for a unilateral large hemicraniectomy, get them through the acute phase, let the swelling of the brain come down and then go back maybe later and revise the other side or something like that. But just doing a bifrontal craniectomy on the front end can be dangerous, both intraoperatively and postoperatively because you're not going to get them enough room to get them through the acute phase. Of course, we try to work as fast as we can to get the job done, but we also keep a very close eye on blood loss. Especially in small children, you can lose the child's blood volume from an injury like this surprisingly fast. So, that leads to the next point is we always try to have aneurysm clips in the room. If you have some arterial vascular injury, it's nice to have aneurysm clips to be able to sacrifice the vessel rather than end up losing more blood than you really are prepared to lose. We also are going ready to perform lobectomies in order to make additional room. If the brain swelling is really severe and the frontal lobe is taking a lot of injury, a lot of times we'll do a frontal lobectomy to make more room to take out some of that injured, dead brain so that postoperatively the child has some room for swelling. We always try to have an exit plan and know when to use it. Sometimes if there's a lot of injury and the brain is swelling really bad and it's really excessive bleeding, sometimes you've got to know when to back away and get out with a less than optimal surgical debridement and maybe get the child out of the OR, get them stable, go back another day and do it again and get them through the acute phase. Obviously, make families aware on the front end. If the family is there, sometimes the family doesn't arrive with the child at the hospital, sometimes they can't find the families, but if they're there, we always try to tell them on the front end this child may not survive the surgery. We're doing this to save their life. We don't know how things are going to go. It's hard to come out of the OR and tell them the child's dead without talking to the family on the front end and giving them the lay of the land. We always put ICP monitors in after the primary debridement is performed. That could be an ICP monitor or possibly a ventriculoscopy catheter or both. Postoperatively, the goal ICP for us is less than 20 centimeters of water or millimeters of mercury depending on what you use. That's pretty standard based on most neurosurgical centers. We attempt to maintain a cerebral perfusion pressure above 40 to 60, which is also fairly standard. We typically only use barbiturate comas as a last resort if all medical and surgical options have been exhausted and the child's ICP is still climbing or very high. We tend to use that as our last-ditch medical effort to try to keep the ICP manageable. Some nursing points that may be of some use to people in the ICU. At Le Bon, our nurses are awesome. They do a fantastic job, especially our neuro-ICU nurses. I trust them more than any other nurse in the city. Coming out of surgery at 2 in the morning, going to the neuro-ICU, these children always get two one-hour neurochecks with continuous monitoring and vital sign measurements. Some tips for children in the ICU who come out of surgery with an ICP monitor is obviously keep the head elevated. We want the head of the bed as high as possible to get gravity and get the blood flow out of the brain to try to lower that ICP. Also, watching the body temperature can help. So if a child is having some central fevers and really warm, a cooling blanket can actually help bring down the ICP, which is another tool you can use in the ICU after surgery. Our typical modus operandi in the ICU is if the child has ICP greater than 20 sustained for greater than 5 minutes, that's what prompts a neurosurgery call. Sometimes just moving a child a little bit can send their ICP pretty high. So we usually say, okay, give it 5 minutes before you call for surgery to do something about it. But our nurses are really good about doing these things in the ICU before they call us and they say, hey, we tried this and we tried this and we tried this, and they're pros when it comes to that. The other thing is a cervical collar. Sometimes because they're a trauma patient and they've hit the door, intubated, the children have a C-collar in place. If they're having trouble with ICP, one of the first things I do when I walk in the rooms, I check the C-collar. And a lot of times the C-collar will be on really tight. And if you loosen that C-collar or take it off altogether, you can drop their ICP by 5 or 10 points sometimes. Now, obviously, if the child's moving around a lot or something and their C-spot hasn't really been cleared, if there's other trauma involved, then you might want to keep the C-collar on. But for the most part, if you have a collar on a child that's having a lot of ICP issues, keeping it loose will help with ICP management. And that's more of a jugular venous flow issue, right? That's the physiological background of lowering ICP by loosening a collar. It's all venous outflow from the brain. And of course, accurate recording of drain output is super important. And not just the JP drains necessarily, but the ventriculostomy. And that can mean too much or even too little. So we want our nurses to call us when there's greater than 20 or greater than 30 in an hour of CSF output from a ventric. But I also want them to call me if it's not putting anything out, right? So you kind of have to watch both ends of the spectrum. Same thing with JP. Sometimes if a JP is really pumping out a lot of blood and the nurse is like, hey, I'm dumping 200 every 20, 30 minutes, you might have an arterial bleeder going on inside still. So our nurses are super helpful when it comes to giving us a call and telling us what's going on. So output's super important. The other one is visitors and stimulation. On a child with really high ICPs and bad brain swelling, there's going to be sometimes a ton of people a family, of course. It's a tragic event. There's a ton of family up there. They all want to see the child. They all want to be in the room. Sometimes that's not a good thing when it comes to ICP, especially in the acute phase, in the middle of the night, the next day. So if we have a child that's really sensitive to stimulation, we say, look, a couple families can go in the room. You've got to be quiet. You can't touch them. Let's leave the stimulation to a minimum, even if they can hear your voice sometimes. If a child can hear you, the ICP will climb. So we try to keep that stimulation to a minimum until their ICPs are better controlled. In general, we try to avoid excessive postoperative imaging, meaning going for a CT every day, because a lot of times if you take a child with an ICP monitor and you lay them flat, their ICP goes up to 30 or 40. That's a problem. So in our opinion, if there's a reason to do a CT, do a CT. But don't just do head CTs every day for surveillance purposes. It's nice to get a post-op CT sometimes, but really I care most about the ICP monitor in the child. When I go in, that's the first thing I look at. What's the number? What's the ICP right now? I'm okay if I've got some kind of exam to follow and an ICP that's 10 to 15. I'm okay with that. I don't need a CT on that child necessarily. And of course, we remove the monitors usually after several days, and that can mean sometimes a week. If the ICP is very labile for five days after surgery, we're going to leave it in until we're comfortable that the ICPs are going to be okay without a monitor in place. And for children, brain swelling can last for like I said, sometimes a week or longer. We really look for exam and ICP stability before we start taking our monitor out. And finally, at least in Tennessee where we are, post-op rehab placement sometimes can be really difficult mostly because we really don't have a good dedicated pediatric rehab facility in our state. A lot of our children end up going to Atlanta or other places where they have larger facilities that can accommodate kids. So that's always something that our case managers are constantly working on is trying to find a place for some of these kids who can't go home and do outpatient therapy. So some of these kids can be in the hospital quite a long time. I'd like to thank my colleagues at Le Bonheur in the neurosurgery department, Dr. Rick Boop and Mike Mulbauer, Stephanie Einhaus and Paul Clemo. They were my teachers coming through training, and they're also my partners, and they're all very good at what they do, and I'm very thankful to have them both as a colleague to work with, but also somebody to bounce questions and other things off of. And at that point, I'll take some questions if there are any. Thank you, Dr. DeCypher. So we're going to open up for questions. You can either raise your hand on the panel, or you can enter a question in the question box, and we'll close it to Dr. DeCypher. So let's take a few minutes for that. I know we're running a little late. Don't see any questions yet. Okay. Well, it doesn't look like we have any questions. I just want to say great job. Thank you, Dr. DeCypher. Oh, my pleasure. Sorry about being late. I apologize. You're fine. So, thank you for all the information you provided us and to all of our attendees. As you digest this information, if you have any – oh, looks like we have a couple of questions. Okay. All right. If you had a transferring facility, what would be some findings that you would defer transfer for? Say that again? If you had a transferring facility, what would be some findings that you would defer transfer for? Oh, you mean like – you mean if like – if someone's trying to transfer the child to me or – Yes, yes. Let me get a little clarity. That's kind of a controversial topic because we deal with this quite a bit where we get children who are sent to Le Bonheur from all over our region. They've been coded for an hour, and they've got no pupils. Those kids, I would say like if they're fixed and dilated, if they're GCS3, if you're still coding them 30 minutes down the road, it's like that child probably needs to be called because that's what's going to happen when they arrive at Le Bonheur most likely is if a child arrives and they've been down for an hour and they're GCS3 and they're fixed and dilated, we call time of death in the ER. We don't even – sometimes don't even necessarily go to get a CT if they're that bad, but that's the sort of situation. So it's hard. I mean it's hard for an ER doctor or a small hospital that may not have neurosurgery coverage to really do that. So we end up getting a lot of transfers. So when in doubt, transfer the patient obviously. But sometimes in those extreme situations, if the child's really unstable and they're actively coding the child and performing CPR, obviously those are situations where I would say don't. Okay. One more question. How do you handle the patient that has received multiple medications prior to your ability to examine them and limit your understanding of their underlying neurosurgical status? Right. That's a tough one too. In those situations when they've had a lot of meds and they're in the ER, if they – let's say their pupils are small and reactive or small and non-reactive, even if they're GCS3, I'm going to take that child to the OR because I know they're probably at least somewhat clouded by sedation or paralytics. On the other hand, if they're fixed and dilated, that's what we tend to hang our hat on is that even if there's a bunch of meds on board, a child is fixed and dilated is a bad sign. So in those situations, what we typically would do is say, okay, they're fixed and dilated. Things look bad. We'll wait and we'll reexamine them in say another 30 minutes or another hour. And if they're still not moving, if they're still a GCS3 and still fixed and dilated, then okay, nothing to do. However, occasionally you'll see unusual bilateral third nerve palsies, which would present with a fixed and dilated child on exam. But if you hold sedation and paralytics long enough, they should start moving. And if a child has fixed and dilated pupils but they're moving or they start having some type of motor exam that's not consistent with a true fixed and dilated herniated situation, we would take that child to the OR. Okay, great. Thank you. Well, we don't have any questions, any further questions, so I think we're going to wrap it up. Thank you, Dr. DeCypher, and thanks everyone for attending our webinar. As you digest the information, if you have any questions, always feel free to email us or call us and we can forward any questions on to Dr. DeCypher. Don't forget, I'll be sending out an email with an evaluation link for you to fill out so that we can continue to improve our offerings. And thank you again for participating in the webinar. Have a great day. Okay, thanks very much. Bye-bye.

pediatric intracranial gunshot wounds

factors associated with survival

mortality rate

surgical intervention

predictive factors

aggressive care

favorable outcome

comprehensive approach