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Lara FR, Sunkavalli P, Mikaelian M, Golemb B, Chung DY, Duhaime AC, Staley K, Costine-Bartell B. Brief apnea with hypoventilation reduces seizure duration and shifts seizure location for several hours in a model of severe traumatic brain injury. Epilepsia 2024; 65:2099-2110. [PMID: 38752982 PMCID: PMC11251852 DOI: 10.1111/epi.17993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/09/2024] [Accepted: 04/09/2024] [Indexed: 07/17/2024]
Abstract
OBJECTIVE Seizures can be difficult to control in infants and toddlers. Seizures with periods of apnea and hypoventilation are common following severe traumatic brain injury (TBI). We previously observed that brief apnea with hypoventilation (A&H) in our severe TBI model acutely interrupted seizures. The current study is designed to determine the effect of A&H on subsequent seizures and whether A&H has potential therapeutic implications. METHODS Piglets (1 week or 1 month old) received multifactorial injuries: cortical impact, mass effect, subdural hematoma, subarachnoid hemorrhage, and seizures induced with kainic acid. A&H (1 min apnea, 10 min hypoventilation) was induced either before or after seizure induction, or control piglets received subdural/subarachnoid hematoma and seizure without A&H. In an intensive care unit, piglets were sedated, intubated, and mechanically ventilated, and epidural electroencephalogram was recorded for an average of 18 h after seizure induction. RESULTS In our severe TBI model, A&H after seizure reduced ipsilateral seizure burden by 80% compared to the same injuries without A&H. In the A&H before seizure induction group, more piglets had exclusively contralateral seizures, although most piglets in all groups had seizures that shifted location throughout the several hours of seizure. After 8-10 h, seizures transitioned to interictal epileptiform discharges regardless of A&H or timing of A&H. SIGNIFICANCE Even brief A&H may alter traumatic seizures. In our preclinical model, we will address the possibility of hypercapnia with normoxia, with controlled intracranial pressure, as a therapeutic option for children with status epilepticus after hemorrhagic TBI.
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Affiliation(s)
| | | | - Michael Mikaelian
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
| | - Bryan Golemb
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
| | - David Y. Chung
- Neurovascular Research Unit, Massachusetts General Hospital, Boston, MA
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
- Department of Neurosurgery, Harvard Medical School, Boston, MA
| | - Kevin Staley
- Department of Neurology, Massachusetts General Hospital, Boston, MA
- Department of Neurology, Harvard Medical School, Boston, MA
| | - Beth Costine-Bartell
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA
- Department of Neurosurgery, Harvard Medical School, Boston, MA
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Holton C, Lee BR, Escobar H, Benton T, Bauer P. Admission Pao2 and Mortality Among PICU Patients and Select Diagnostic Subgroups. Pediatr Crit Care Med 2023:00130478-990000000-00177. [PMID: 37092837 DOI: 10.1097/pcc.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Evaluate the relationship between admission Pao2 and mortality in a large multicenter dataset and among diagnostic subgroups. DESIGN Retrospective cohort study. SETTING North American PICUs participating in Virtual Pediatric Systems, LLC (VPS), 2015-2019. PATIENTS Noncardiac patients 18 years or younger admitted to a VPS PICU with admission Pao2. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirteen thousand seventy-one patient encounters were included with an overall mortality of 13.52%. Age categories were equally distributed among survivors and nonsurvivors with the exception of small differences among neonates and adolescents. Importantly, there was a tightly fitting quadratic relationship between admission Pao2 and mortality, with the highest mortality rates seen among hypoxemic and hyperoxemic patients (likelihood-ratio test p < 0.001). This relationship persisted after adjustment for illness severity using modified Pediatric Index of Mortality 3 scores. A similar U-shaped relationship was demonstrated among patients with diagnoses of trauma, head trauma, sepsis, renal failure, hemorrhagic shock, and drowning. However, among the 1,500 patients admitted following cardiac arrest, there was no clear relationship between admission Pao2 and mortality. CONCLUSIONS In a large multicenter pediatric cohort, admission Pao2 demonstrates a tightly fitting quadratic relationship with mortality. The persistence of this relationship among some but not all diagnostic subgroups suggests the pathophysiology of certain disease states may modify the hyperoxemia association.
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Affiliation(s)
- Caroline Holton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Brian R Lee
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO
| | - Hugo Escobar
- Division of Pulmonology, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Tara Benton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Paul Bauer
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
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Chao M, Wang CC, Chen CPC, Chung CY, Ouyang CH, Chen CC. The Influence of Serious Extracranial Injury on In-Hospital Mortality in Children with Severe Traumatic Brain Injury. J Pers Med 2022; 12:jpm12071075. [PMID: 35887572 PMCID: PMC9323906 DOI: 10.3390/jpm12071075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Serious extracranial injury (SEI) commonly coexists with sTBI after the high impact of trauma. Limited studies evaluate the influence of SEI on the prognosis of pediatric sTBI. We aimed to analyze SEI’s clinical characteristics and initial presentations and evaluate if SEI is predictive of higher in-hospital mortality in these sTBI children. (2) Methods: In this 11-year-observational cohort study, a total of 148 severe sTBI children were enrolled. We collected patients’ initial data in the emergency department, including gender, age, mechanism of injury, coexisting SEI, motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and intracranial Rotterdam computed tomography (CT) score of the first brain CT scan, as potential mortality predictors. (3) Results: Compared to sTBI children without SEI, children with SEI were older and more presented with initial hypotension and hypothermia; the initial lab showed more prolonged prothrombin time and a higher in-hospital mortality rate. Multivariate analysis showed that motor components of mGCS, fixed pupil reaction, prolonged prothrombin time, and higher Rotterdam CT score were independent predictors of in-hospital mortality in sTBI children. SEI was not an independent predictor of mortality. (4) Conclusions: sTBI children with SEI had significantly higher in-hospital mortality than those without. SEI was not an independent predictor of mortality in our study. Brain injury intensity and its presentations, including lower mGCS, fixed pupil reaction, higher Rotterdam CT score, and severe injury-induced systemic response, presented as initial prolonged prothrombin time, were independent predictors of in-hospital mortality in these sTBI children.
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Affiliation(s)
- Min Chao
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Cheng Wang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Carl P. C. Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
| | - Chun-Hsiang Ouyang
- Department of Traumatology and Emergency Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (C.-C.W.); (C.-H.O.)
| | - Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan 33305, Taiwan; (M.C.); (C.P.C.C.); (C.-Y.C.)
- Correspondence:
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Pelletier JH, Ramgopal S, Horvat CM. Hyperoxemia Is Associated With Mortality in Critically Ill Children. Front Med (Lausanne) 2021; 8:675293. [PMID: 34164417 PMCID: PMC8215123 DOI: 10.3389/fmed.2021.675293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/27/2021] [Indexed: 11/26/2022] Open
Abstract
Multiple studies among adults have suggested a non-linear relationship between arterial partial pressure of oxygen (PaO2) and clinical outcomes. Meta-analyses in this population suggest that high levels of supplemental oxygen resulting in hyperoxia are associated with mortality. This mini-review focuses on the non-neonatal pediatric literature examining the relationship between PaO2 and mortality. While only one pilot pediatric randomized-controlled trials exists, over the past decade, there have been at least eleven observational studies examining the relationship between PaO2 values and mortality in critically ill children. These analyses of mixed-case pediatric ICU populations have generally reported a parabolic (“u-shaped”) relationship between PaO2 and mortality, similar to that seen in the adult literature. However, the estimates of the point at which hyperoxemia becomes deleterious have varied widely (300–550 mmHg). Where attempted, this effect has been robust to analyses restricted to the first PaO2 value obtained, those obtained within 24 h of admission, anytime during admission, and the number of hyperoxemic blood gases over time. These findings have also been noted when using various methods of risk-adjustment (accounting for severity of illness scores or complex chronic conditions). Similar relationships were found in the majority of studies restricted to patients undergoing care after cardiac arrest. Taken together, the majority of the literature suggests that there is a robust parabolic relationship between PaO2 and risk-adjusted pediatric ICU mortality, but that the exact threshold at which hyperoxemia becomes deleterious is unclear, and likely beyond the typical target value for most clinical indications. Findings suggest that clinicians should remain judicious and thoughtful in the use of supplemental oxygen therapy in critically ill children.
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Affiliation(s)
- Jonathan H Pelletier
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Sriram Ramgopal
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Christopher M Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Division of Health Informatics, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
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Ketharanathan N, De Jonge RCJ, Klouwen I, Wildschut ED, Reiss IKM, Tibboel D, Haitsma IKM, Buysse CMP. Hyperoxia in pediatric severe traumatic brain injury (TBI): a comparison of patient classification by cutoff versus cumulative (area-under-the-curve) analysis. Brain Inj 2020; 34:958-964. [PMID: 32485120 DOI: 10.1080/02699052.2020.1765021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Hyperoxia is associated with adverse outcome in severe traumatic brain injury (TBI). This study explored differences in patient classification of oxygen exposure by PaO2 cutoff and cumulative area-under-the-curve (AUC) analysis. METHODS Retrospective, explorative study including children (<18 years) with accidental severe TBI (2002-2015). Oxygen exposure analysis used three PaO2 cutoff values and four PaO2 AUC categories during the first 24 hours of Pediatric Intensive Care Unit (PICU) admission. RESULTS Seventy-one patients were included (median age 8.9 years [IQR 4.6-12.9]), mortality 18.3% (n = 13). Patient hyperoxia classification differed depending on PaO2 cutoff vs AUC analysis: 52% vs. 26%, respectively, were classified in the highest hyperoxia category. Eleven patients (17%) classified as 'intermediate oxygen exposure' based on cumulative PaO2 analysis whereby they did not exceed the 200 mmHg PaO2 cutoff threshold. Patient classification variability was reflected by Pearson correlation coefficient of 0.40 (p-value 0.001). CONCLUSIONS Hyperoxia classification in pediatric severe TBI during the first 24 hours of PICU admission differed depending on PaO2 cutoff or cumulative AUC analysis. We consider PaO2 cumulative (AUC) better approximates (patho-)physiological circumstances due to its time- and dose-dependent approach. Prospective studies exploring the association between cumulative PaO2, physiological parameters (e.g. ICP, PbtO2) and outcome are warranted as different patient classifications of oxygen exposure influences how its relationship to outcome is interpreted.
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Affiliation(s)
- Naomi Ketharanathan
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Rogier C J De Jonge
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Ilse Klouwen
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Enno D Wildschut
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Irwin K M Reiss
- Department of Pediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Iain K M Haitsma
- Department of Neurosurgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
| | - Corinne M P Buysse
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital , Rotterdam, The Netherlands
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Abstract
Hyperventilation is commonly used in neurological patients to decrease elevated intracranial pressure (ICP) or relax a tense brain. However, the potentially deleterious effects of hyperventilation may limit its clinical application. The aim of this review is to summarize the physiological and outcome evidence related to hyperventilation in neurological patients.
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Naylor JF, Borgman MA, April MD, Hill GJ, Schauer SG. Normobaric hyperoxia in wartime pediatric trauma casualties. Am J Emerg Med 2019; 38:709-714. [PMID: 31182364 DOI: 10.1016/j.ajem.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/01/2019] [Accepted: 06/02/2019] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Mounting evidence suggests hyperoxia therapy may be harmful. We describe injury characteristics and survival outcomes for pediatric trauma casualties in Iraq and Afghanistan, stratified by partial pressure of arterial oxygen (PaO2). Secondarily, we performed subgroup analyses for severe traumatic brain injury (TBI) and massive transfusion of blood products (MT). METHODS We utilized Department of Defense Trauma Registry data. We included subjects <18 years. We excluded subjects without an arterial blood gas (ABG). We stratified subjects as hyperoxemia (PaO2 100-300 mmHg) and extreme hyperoxemia (PaO2 >300 mmHg). RESULTS January 2007-January 2016, 3439 pediatric encounters were in the database. Of those, 1323 had an ABG, with 291 (22%) demonstrating hyperoxemia and 43 (3.3%) extreme hyperoxemia. The median age was 8, most were male (76%) in Afghanistan (69%), and injured by explosive (42%). There were no significant differences in survival between subjects with no hyperoxemia, hyperoxemia, and extreme hyperoxemia (92% vs 87% vs 86%; p = 0.078). Also, there were no significant differences in survival between groups among TBI and MT subjects, and there were no increased odds of survival between groups on multivariable regression analyses. CONCLUSIONS Hyperoxemia was common among hospitalized, wartime pediatric trauma casualties in Iraq and Afghanistan that underwent ABG analysis. Survival to hospital discharge rates were not significantly different between subjects with hyperoxemia and subjects without hyperoxemia.
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Affiliation(s)
- Jason F Naylor
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington 98431, United States of America.
| | - Matthew A Borgman
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America
| | - Michael D April
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America
| | - Guyon J Hill
- Madigan Army Medical Center, Joint Base Lewis-McChord, Washington 98431, United States of America
| | - Steven G Schauer
- Brooke Army Medical Center, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America; US Army Institute of Surgical Research, Joint Base San Antonio - Fort Sam Houston, TX 78243, United States of America; 59(th) Medical Wing, Joint Base San Antonio - Lackland, TX 78236, United States of America
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8
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Abstract
PURPOSE OF REVIEW Traumatic brain injury (TBI) is a leading cause of death and disability in children. Prognostication of outcome following TBI is challenging in this population and likely requires complex, multimodal models to achieve clinically relevant accuracy. This review highlights injury characteristics, physiological indicators, biomarkers and neuromonitoring modalities predictive of outcome that may be integrated for future development of sensitive and specific prognostic models. RECENT FINDINGS Paediatric TBI is responsible for physical, psychosocial and neurocognitive deficits that may significantly impact quality of life. Outcome prognostication can be difficult in the immature brain, but is aided by the identification of novel biomarkers (neuronal, astroglial, myelin, inflammatory, apoptotic and autophagic) and neuromonitoring techniques (electroencephalogram and MRI). Investigation in the future may focus on assessing the prognostic ability of combinations of biochemical, protein, neuroimaging and functional biomarkers and the use of mathematical models to develop multivariable predication tools to improve the prognostic ability following childhood TBI. SUMMARY Prognostication of outcome following paediatric TBI is multidimensional, influenced by injury severity, age, physiological factors, biomarkers, electroencephalogram and neuroimaging. Further development, integration and validation of combinatorial prognostic algorithms are necessary to improve the accuracy and timeliness of prognosis in a meaningful fashion.
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Abstract
OBJECTIVES We analyzed a prospective database of pediatric traumatic brain injury patients to identify predictors of outcome and describe the change in function over time. We hypothesized that neurologic status at hospital discharge would not reflect the long-term neurologic recovery state. DESIGN This is a descriptive cohort analysis of a single-center prospective database of pediatric traumatic brain injury patients from 2001 to 2012. Functional outcome was assessed at hospital discharge, and the Glasgow Outcome Scale Extended Pediatrics or Glasgow Outcome Scale was assessed on average at 15.8 months after injury. SETTING Children's Medical Center Dallas, a single-center PICU and Level 1 Trauma Center. PATIENTS Patients, 0-17 years old, with complicated-mild/moderate or severe accidental traumatic brain injury. MEASUREMENTS AND MAIN RESULTS Dichotomized long-term outcome was favorable in 217 of 258 patients (84%), 80 of 82 patients (98%) with complicated-mild/moderate injury and 133 of 172 severe patients (77%). In the bivariate analysis, younger age, motor vehicle collision as a mechanism of injury, intracranial pressure monitor placement, cardiopulmonary resuscitation at scene or emergency department, increased hospital length of stay, increased ventilator days (all with p < 0.01) and occurrence of seizures (p = 0.03) were significantly associated with an unfavorable outcome. In multiple regression analysis, younger age (p = 0.03), motor vehicle collision (p = 0.01), cardiopulmonary resuscitation (p < 0.01), and ventilator days (p < 0.01) remained significant. Remarkably, 28 of 60 children (47%) with an unfavorable Glasgow Outcome Scale at hospital discharge improved to a favorable outcome. In severe patients with an unfavorable outcome at hospital discharge, younger age was identified as a risk factor for remaining in an unfavorable condition (p = 0.1). CONCLUSIONS Despite a poor neurologic status at hospital discharge, many children after traumatic brain injury will significantly improve at long-term assessment. The factors most associated with outcomes were age, cardiopulmonary resuscitation, motor vehicle collision, intracranial pressure placement, days on a ventilator, hospital length of stay, and seizures. The factor most associated with improvement from an unfavorable neurologic status at discharge was being older.
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Hyperoxia and Hypocapnia During Pediatric Extracorporeal Membrane Oxygenation: Associations With Complications, Mortality, and Functional Status Among Survivors. Pediatr Crit Care Med 2018; 19:245-253. [PMID: 29319634 PMCID: PMC5834382 DOI: 10.1097/pcc.0000000000001439] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the frequency of hyperoxia and hypocapnia during pediatric extracorporeal membrane oxygenation and their relationships to complications, mortality, and functional status among survivors. DESIGN Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network. SETTING Eight Collaborative Pediatric Critical Care Research Network-affiliated hospitals. PATIENTS Age less than 19 years and treated with extracorporeal membrane oxygenation. INTERVENTIONS Hyperoxia was defined as highest PaO2 greater than 200 Torr (27 kPa) and hypocapnia as lowest PaCO2 less than 30 Torr (3.9 kPa) during the first 48 hours of extracorporeal membrane oxygenation. Functional status at hospital discharge was evaluated among survivors using the Functional Status Scale. MEASUREMENTS AND MAIN RESULTS Of 484 patients, 420 (86.7%) had venoarterial extracorporeal membrane oxygenation and 64 (13.2%) venovenous; 69 (14.2%) had extracorporeal membrane oxygenation initiated during cardiopulmonary resuscitation. Hyperoxia occurred in 331 (68.4%) and hypocapnia in 98 (20.2%). Hyperoxic patients had higher mortality than patients without hyperoxia (167 [50.5%] vs 48 [31.4%]; p < 0.001), but no difference in functional status among survivors. Hypocapnic patients were more likely to have a neurologic event (49 [50.0%] vs 143 (37.0%]; p = 0.021) or hepatic dysfunction (49 [50.0%] vs 121 [31.3%]; p < 0.001) than patients without hypocapnia, but no difference in mortality or functional status among survivors. On multivariable analysis, factors independently associated with increased mortality included highest PaO2 and highest blood lactate concentration in the first 48 hours of extracorporeal membrane oxygenation, congenital diaphragmatic hernia, and being a preterm neonate. Factors independently associated with lower mortality included meconium aspiration syndrome. CONCLUSIONS Hyperoxia is common during pediatric extracorporeal membrane oxygenation and associated with mortality. Hypocapnia appears to occur less often and although associated with complications, an association with mortality was not observed.
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Hamilton C, Maw A, Gill A, Brahmbhatt M, Phaal R, Pickard J. Paediatric neurorehabilitation: finding and filling the gaps through the use of the Institute for Manufacturing strategic roadmapping method. ACTA ACUST UNITED AC 2017. [DOI: 10.1136/bmjinnov-2017-000202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionAcquired brain injury (ABI) is a major cause of morbidity and mortality in childhood. Specialist rehabilitation services are often situated far from families and local services may be non-standardised and fragmented. A strategic level of understanding is needed to improve patient care and outcomes. Roadmapping techniques are commonly used in industry settings to discover and present a systematic understanding of structures; however, they are rarely used in the healthcare setting. With continuing pressures on healthcare systems worldwide, they provide an effective method for examining services.MethodsThe Institute for Manufacturing (IfM) strategic roadmapping method was used to identify areas of difficulty and opportunities in paediatric neurorehabilitation. Participants included stakeholders from a wide range of professions and sectors who have input with children after ABI.ResultsDelegates identified a range of ‘layers’ covering trends, drivers, current experience and unmet needs. From these layers, four priorities were identified and further expanded.These included: ‘access to medical and therapy expertise close(r) to home’, ‘shared understanding across family, school and health’, ‘family and professional awareness of resources and support’ and ‘establishing a centre for rehabilitation technology evaluation, advice and co-ordination of services and research’.ConclusionThe IfM strategic roadmapping method identified and developed key areas for development in the field of paediatric neurological rehabilitation. Healthcare professionals looking at strategic level difficulties should strongly consider the use of such systematic tools when evaluating areas of practice.
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Ventilation Monitoring in Severe Pediatric Traumatic Brain Injury at Nontrauma Centers. Air Med J 2016; 34:278-82. [PMID: 26354304 DOI: 10.1016/j.amj.2015.05.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 04/23/2015] [Accepted: 05/30/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Pediatric traumatic brain injury (TBI) guidelines should direct patient management. This retrospective study compared ventilation monitoring practices of nontrauma center (NTC) personnel and air medical crews (AMCs) in pediatric patients with severe TBI at NTCs after endotracheal intubation. METHODS Pediatric patient charts for level I trauma center admissions between 2008 and 2013 with severe TBI were screened. Inclusion criteria included admission Glasgow Coma Scale score ≤ 8, head Abbreviated Injury Scale score of ≥ 3, and secure airway initiated or managed at an NTC. RESULTS A total of 30 patients were evaluated. The median head Abbreviated Injury Scale score was 4, and the trauma center mortality rate was 30%. NTC personnel and AMCs intubated 22 and 8 patients, respectively. AMCs monitored ventilation with much greater regularity (100 vs. 41%, P = .004), used continuous waveform capnography more often (75 vs. 14%, P = .003), and also initiated it quicker (17 vs. 37 minutes, = .001) after intubation. Unmonitored patients from NTC intubations waited on average 72.3 minutes before interfacility transport to the trauma center. CONCLUSIONS AMCs showed superior ventilation monitoring after intubation in pediatric patients with severe TBI. Ventilation monitoring was not routinely conducted by NTC personnel, signifying areas to improve patient care.
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Abstract
OBJECTIVE To describe the relationship between PaO2 at intensive care admission and mortality in critically ill children and to review systematically the literature describing this relationship. DESIGN Cohort study: A review of consecutive tertiary pediatric intensive care admissions (January 2004 to December 2014) in a single center. The relationship between admission Pao2 and crude and standardized mortality was explored using nonlinear regression. Systematic review: A search of MEDLINE (1950 to January 2015), EMBASE (1980 to January 2015), Cochrane and Database of Abstracts of Reviews of Effects databases was undertaken using the following terms: "hyperoxia," "hypoxia," "critically ill children," "pediatric intensive care," "mortality," and/or "survival." SETTING Tertiary PICU. PATIENTS Patients younger than 18 years of age. INTERVENTIONS The association of hyperoxia (PaO2, > 300 torr [40 kPa]) and hypoxia (PaO2, < 60 torr [8 kPa] or peripheral oxygen saturations, < 90%) to mortality in critically ill children was explored. MEASUREMENTS AND MAIN RESULTS Cohort study: Of 14,321 admissions, 7,410 children had recorded PaO2 and FIO2 at admission. Crude mortality was 7.4% (555/7,410). This varied with admission PaO2 from 15.4% (204/1,324) in the hypoxia group (< 8 kPa) to 5.3% (287/5,385) with normoxia and 9.1% (64/701) in the hyperoxic group (> 40 kPa). Nonlinear regression displayed a "U-shaped" relationship between PaO2 and crude and case-mix adjusted mortality. Systematic review: Fourteen studies and one conference abstract were eligible for inclusion. Eleven studies (n = 5,280) relate to hypoxia with combined odds ratio for death, of 3.13 (95% CI, 1.79-5.48; p < 0.001) compared to normoxia. Six studies (n = 2,012) relate to hyperoxia and suggest no effect on mortality compared to normoxia (odds ratio, 1.15; 95% CI, 0.42-3.17; p = 0.77). CONCLUSIONS Hypoxia at admission is associated with increased mortality in critically ill children, whereas the association with hyperoxia is less clear. The cohort study demonstrated a U-shaped association between admission PaO2 and mortality. Further examination is needed to explore the effect of hyperoxia upon mortality prediction accuracy.
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15
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Abstract
Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.
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16
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Rettig JS, Duncan ED, Tasker RC. Mechanical Ventilation during Acute Brain-Injury in Children. Paediatr Respir Rev 2016; 20:17-23. [PMID: 26972477 DOI: 10.1016/j.prrv.2016.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/10/2016] [Indexed: 01/05/2023]
Abstract
Mechanical ventilation in the brain-injured pediatric patient requires many considerations, including the type and severity of lung and brain injury and how progression of such injury will develop. This review focuses on neurological breathing patterns at presentation, the effect of brain injury on the lung, developmental aspects of blood gas tensions on cerebral blood flow, and strategies used during mechanical ventilation in infants and children receiving neurological intensive care. Taking these basic principles, our clinical approach is informed by balancing the blood gas tension targets that follow from the ventilation support we choose and the intracranial consequences of these choices on vascular and hydrodynamic physiology. As such, we are left with two key decisions: a low tidal volume strategy for the lung versus the consequence of hypercapnia on the brain; and the use of positive end expiratory pressure to optimize oxygenation versus the consequence of impaired cerebral venous return from the brain and resultant intracranial hypertension.
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Affiliation(s)
- Jordan S Rettig
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine
| | - Elizabeth D Duncan
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine
| | - Robert C Tasker
- Department of Anesthesiology, Perioperative and Pain Medicine, Division of Critical Care Medicine; Department of Neurology; Boston Children's Hospital and Harvard Medical School, Boston, MA.
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17
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Simon DW, Vagni VM, Kochanek PM, Clark RSB. Combined Neurotrauma Models: Experimental Models Combining Traumatic Brain Injury and Secondary Insults. Methods Mol Biol 2016; 1462:393-411. [PMID: 27604730 DOI: 10.1007/978-1-4939-3816-2_22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Patients with severe traumatic brain injury (TBI) frequently present with concomitant injuries that may cause secondary brain injury and impact outcomes. Animal models have been developed that combine contemporary models of TBI with a secondary neurologic insult such as hypoxia, shock, long bone fracture, and radiation exposure. Combined injury models may be particularly useful when modeling treatment strategies and in efforts to map basic research to a heterogeneous patient population. Here, we review these models and their collective contribution to the literature on TBI. In addition, we provide protocols and notes for two well-characterized models of TBI plus hemorrhagic shock.
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Affiliation(s)
- Dennis W Simon
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vincent M Vagni
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- The Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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18
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Hansen G, Vallance JK. Ventilation monitoring for severe pediatric traumatic brain injury during interfacility transport. Int J Emerg Med 2015; 8:41. [PMID: 26572880 PMCID: PMC4646896 DOI: 10.1186/s12245-015-0091-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 11/12/2015] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Ventilation monitoring practice for intubated pediatric patients with severe traumatic brain injury (TBI) during interfacility transport (IFT) has not been well documented. We describe the difference of practices in ventilation monitoring during IFT from the perspective of a level I pediatric trauma center with an enormous catchment area. METHODS Patients admitted between July 2008 and September 2013 at Winnipeg Health Science Center, Canada, were examined in this retrospective chart review. All patients with severe TBI were intubated in regional health centers and required transport to the level 1 trauma center. Injuries due to inflicted head trauma (<5 years of age), stroke, drowning, and asphyxia were excluded. Patient characteristics, injury data, ventilation monitoring, and transport metrics were obtained from a regional health center, and transport and trauma center charts. RESULTS Thirty four patients were studied. Specialty transport teams utilized ventilation monitoring significantly more often (95 vs. 23 %; p < 0.001) than non-specialized ground transport. Specialty teams were more likely to obtain a blood gas prior to departure (74 vs. 0 %; p = 0.037) if end-tidal monitoring was used. Among unmonitored ground transport patients, mean transport time was 69.1 min. CONCLUSIONS Non-specialized ground IFT teams did not reliably monitor ventilation in intubated severe pediatric TBI patients. Blood gas monitoring was not a ubiquitous practice for either team. Optimal ventilation monitoring strategies for severe pediatric TBI may require both blood gas and end-tidal monitoring.
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Affiliation(s)
- Gregory Hansen
- Section of Pediatric Intensive Care, Department of Pediatrics and Child Health, Children's Hospital, University of Manitoba, Room 564 John Buhler Research Centre, 715 McDermot Avenue, Winnipeg, Manitoba, R3E 3P4, Canada.
| | - Jeff K Vallance
- Faculty of Health Disciplines, Athabasca University, Athabasca, Alberta, Canada.
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Fulkerson DH, White IK, Rees JM, Baumanis MM, Smith JL, Ackerman LL, Boaz JC, Luerssen TG. Analysis of long-term (median 10.5 years) outcomes in children presenting with traumatic brain injury and an initial Glasgow Coma Scale score of 3 or 4. J Neurosurg Pediatr 2015; 16:410-9. [PMID: 26140392 DOI: 10.3171/2015.3.peds14679] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Patients with traumatic brain injury (TBI) with low presenting Glasgow Coma Scale (GCS) scores have very high morbidity and mortality rates. Neurosurgeons may be faced with difficult decisions in managing the most severely injured (GCS scores of 3 or 4) patients. The situation may be considered hopeless, with little chance of a functional recovery. Long-term data are limited regarding the clinical outcome of children with severe head injury. The authors evaluate predictor variables and the clinical outcomes at discharge, 1 year, and long term (median 10.5 years) in a cohort of children with TBI presenting with postresuscitation GCS scores of 3 and 4. METHODS A review of a prospectively collected trauma database was performed. Patients treated at Riley Hospital for Children (Indianapolis, Indiana) from 1988 to 2004 were reviewed. All children with initial GCS (modified for pediatric patients) scores of 3 or 4 were identified. Patients with a GCS score of 3 were compared with those with a GCS score of 4. The outcomes of all patients at the time of death or discharge and at 1-year and long-term follow-up were measured with a modified Glasgow Outcome Scale (GOS) that included a "normal" outcome. Long-term outcomes were evaluated by contacting surviving patients. Statistical "classification trees" were formed for survival and outcome, based on predictor variables. RESULTS Sixty-seven patients with a GCS score of 3 or 4 were identified in a database of 1636 patients (4.1%). Three of the presenting factors differed between the GCS 3 patients (n = 44) and the GCS 4 patients (n = 23): presence of hypoxia, single seizure, and open basilar cisterns on CT scan. The clinical outcomes were statistically similar between the 2 groups. In total, 48 (71.6%) of 67 patients died, remained vegetative, or were severely disabled by 1 year. Eight patients (11.9%) were normal at 1 year. Ten of the 22 patients with long-term follow-up were either normal or had a GOS score of 5. Multiple clinical, historical, and radiological factors were analyzed for correlation with survival and clinical outcome. Classification trees were formed to stratify predictive factors. The pupillary response was the factor most predictive of both survival and outcome. Other factors that either positively or negatively correlated with survival included hypothermia, mechanism of injury (abuse), hypotension, major concurrent symptoms, and midline shift on CT scan. Other factors that either positively or negatively predicted long-term outcome included hypothermia, mechanism of injury, and the assessment of the fontanelle. CONCLUSIONS In this cohort of 67 TBI patients with a presenting GCS score of 3 or 4, 56.6% died within 1 year. However, approximately 15% of patients had a good outcome at 10 or more years. Factors that correlated with survival and outcome included the pupillary response, hypothermia, and mechanism. The authors discuss factors that may help surgeons make critical decisions regarding their most serious pediatric trauma patients.
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Affiliation(s)
- Daniel H Fulkerson
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Ian K White
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jacqueline M Rees
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Maraya M Baumanis
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jodi L Smith
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Laurie L Ackerman
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Joel C Boaz
- Department of Neurological Surgery, Division of Pediatric Neurosurgery, Goodman Campbell Brain and Spine
| | - Thomas G Luerssen
- Department of Neurological Surgery, Baylor College of Medicine, Texas Children's Hospital, Pediatric Neurosurgery, Houston, Texas
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20
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Chong SL, Lee KP, Lee JH, Ong GYK, Ong MEH. Pediatric head injury: a pain for the emergency physician? Clin Exp Emerg Med 2015; 2:1-8. [PMID: 27752566 PMCID: PMC5052852 DOI: 10.15441/ceem.14.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 01/10/2015] [Accepted: 01/26/2015] [Indexed: 11/23/2022] Open
Abstract
The prompt diagnosis and initial management of pediatric traumatic brain injury poses many challenges to the emergency department (ED) physician. In this review, we aim to appraise the literature on specific management issues faced in the ED, specifically: indications for neuroimaging, choice of sedatives, applicability of hyperventilation, utility of hyperosmolar agents, prophylactic anti-epileptics, and effect of hypothermia in traumatic brain injury. A comprehensive literature search of PubMed and Embase was performed in each specific area of focus corresponding to the relevant questions. The majority of the head injured patients presenting to the ED are mild and can be observed. Clinical prediction rules assist the ED physician in deciding if neuroimaging is warranted. In cases of major head injury, prompt airway control and careful use of sedation are necessary to minimize the chance of hypoxia, while avoiding hyperventilation. Hyperosmolar agents should be started in these cases and normothermia maintained. The majority of the evidence is derived from adult studies, and most treatment modalities are still controversial. Recent multicenter trials have highlighted the need to establish common platforms for further collaboration.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Khai Pin Lee
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore
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21
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Roberts BW, Karagiannis P, Coletta M, Kilgannon JH, Chansky ME, Trzeciak S. Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review. Resuscitation 2015; 91:32-41. [PMID: 25828950 DOI: 10.1016/j.resuscitation.2015.03.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 02/04/2015] [Accepted: 03/09/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Partial pressure of arterial carbon dioxide (PaCO2) is a major regulator of cerebral blood flow (CBF). Derangements in PaCO2 have been thought to worsen clinical outcomes after many forms of cerebral injury by altering CBF. Our aim was to systematically analyze the biomedical literature to determine the effects of PaCO2 derangements on clinical outcomes after cerebral injury. METHODS We performed a search of Cochrane Library, PUBMED, CINHAL, conference proceedings, and other sources using a comprehensive strategy. Study inclusion criteria were (1) human subjects; (2) cerebral injury; (3) mechanical ventilation post-injury; (4) measurement of PaCO2; and (5) comparison of a clinical outcome measure (e.g. mortality) between different PaCO2 exposures. We performed a qualitative analysis to collate and summarize effects of PaCO2 derangements according to the recommended methodology from the Cochrane Handbook. RESULTS Seventeen studies involving different etiologies of cerebral injury (six traumatic brain injury, six post-cardiac arrest syndrome, two cerebral vascular accident, three neonatal ischemic encephalopathy) met all inclusion and no exclusion criteria. Three randomized control trials were identified and only one was considered a high quality study as per the Cochrane criteria for assessing risk of bias. In 13/17 (76%) studies examining hypocapnia, and 7/10 (70%) studies examining hypercapnia, the exposed group (hypercapnia or hypocapnia) was associated with poor clinical outcome. CONCLUSION The majority of studies in this report found exposure to hypocapnia and hypercapnia after cerebral injury to be associated with poor clinical outcome. However, the optimal PaCO2 range associated with good clinical outcome remains unclear.
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Affiliation(s)
- Brian W Roberts
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Paul Karagiannis
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael Coletta
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - J Hope Kilgannon
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Michael E Chansky
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Stephen Trzeciak
- Department of Emergency Medicine, Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA; Department of Medicine, Division of Critical Care Medicine (ST), Cooper University Hospital and Cooper Medical School of Rowan University, Camden, NJ, USA.
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