Management of severe pediatric head trauma

Traumatic Brain Injury: Comparison of Computed Tomography Findings in Pediatric and Adult Populations

Introduction Traumatic brain injury (TBI) is a global health issue, accounting for a significant number of adult and pediatric deaths and morbidity. Computed tomography (CT) is an important diagnostic modality for TBI. The primary goal of this study was to determine if there were any significant radiological differences in CT brain findings between adult and pediatric populations.

Materials and Methods Data of individual patients were collected from admission to discharge/death, which included various parameters in terms of demographics, mechanism of injury, and patient outcome which were later analyzed. A total of 1,150 TBI patients were enrolled in the study.

Results The most common mode of injury in adults is road traffic accident (RTA) followed by fall from height (FFH), while in pediatrics it is vice versa. Findings of basal cisterns on CT brain were found to be statistically significant in both groups; 65% adults and 71% pediatrics had only one abnormal CT finding. Most common combination CT finding in adults was acute subdural hematoma (ASDH) and basal cistern abnormality, while in pediatrics it was traumatic subarachnoid hemorrhage (SAH) and contusion. Rotterdam score (based on CT brain findings) was significantly lower for pediatric age group compared with adults. It was 2.2 ± 0.85 for adults and 1.99 ± 0.74 for pediatrics, which was statistically significant (p < 0.001).

Conclusions The Rotterdam score has immense predictive power for prognostication of mortality status. Pediatric age group has better prognosis in terms of survival as compared with adults, thus justifying the role of Rotterdam CT score for mortality risk stratification in providing clinical care.

Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology

Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.

Computed tomography characteristics in pediatric versus adult traumatic brain injury

OBJECT

Traumatic brain injury (TBI) is a leading cause of injury, hospitalization, and death among pediatric patients. Admission CT scans play an important role in classifying TBI and directing clinical care, but little is known about the differences in CT findings between pediatric and adult patients. The aim of this study was to determine if radiographic differences exist between adult and pediatric TBI.

METHODS

The authors retrospectively analyzed TBI registry data from 1206 consecutive patients with nonpenetrating TBI treated at a Level 1 adult and pediatric trauma center over a 30-month period.

RESULTS

The distribution of sex, race, and Glasgow Coma Scale (GCS) score was not significantly different between the adult and pediatric populations; however, the distribution of CT findings was significantly different. Pediatric patients with TBI were more likely to have skull fractures (OR 3.21, p < 0.01) and epidural hematomas (OR 1.96, p < 0.01). Pediatric TBI was less likely to be associated with contusion, subdural hematoma, subarachnoid hemorrhage, or compression of the basal cisterns (p < 0.05). Rotterdam CT scores were significantly lower in the pediatric population (2.3 vs 2.6, p < 0.001).

CONCLUSIONS

There are significant differences in the CT findings in pediatric versus adult TBI, despite statistical similarities with regard to clinical severity of injury as measured by the GCS. These differences may be due to anatomical characteristics, the biomechanics of injury, and/or differences in injury mechanisms between pediatric and adult patients. The unique characteristics of pediatric TBI warrant consideration when formulating a clinical trial design or predicting functional outcome using prognostic models developed from adult TBI data.

The development of pediatric critical care medicine at The Children's Hospital of Philadelphia: an interview with Dr. John J. 'Jack' Downes

Dr. John J. 'Jack' Downes (1930-), the anesthesiologist-in-chief at The Children's Hospital of Philadelphia (1972-1996), has made numerous contributions to pediatric anesthesia and critical care medicine through a broad spectrum of research on chronic respiratory failure, status asthmaticus, postoperative risks of apnea in premature infants, and home-assisted mechanical ventilation. However, his defining moment was in January 1967, when The Children's Hospital of Philadelphia inaugurated its pediatric intensive care unit--the first of its kind in North America. During his tenure, he and his colleagues trained an entire generation of pediatric anesthesiologists and intensivists and set a standard of care and professionalism that continues to the present day. Based on an interview with Dr. Downes, this article reviews a career that advanced pediatric anesthesia and critical care medicine and describes the development of that first pediatric intensive care unit at The Children's Hospital of Philadelphia.

Experimental mild traumatic brain injury induces functional alteration of the developing hippocampus

It is estimated that approximately 1.5 million Americans suffer a traumatic brain injury (TBI) every year, of which approximately 80% are considered mild injuries. Because symptoms caused by mild TBI last less than half an hour by definition and apparently resolve without treatment, the study of mild TBI is often neglected resulting in a significant knowledge gap for this wide-spread problem. In this work, we studied functional (electrophysiological) alterations of the neonatal/juvenile hippocampus after experimental mild TBI. Our previous work reported significant cell death after in vitro injury >10% biaxial deformation. Here we report that biaxial deformation as low as 5% affected neuronal function during the first week after in vitro mild injury of hippocampal slice cultures. These results suggest that even very mild mechanical events may lead to a quantifiable neuronal network dysfunction. Furthermore, our results highlight that safe limits of mechanical deformation or tolerance criteria may be specific to a particular outcome measure and that neuronal function is a more sensitive measure of injury than cell death. In addition, the age of the tissue at injury was found to be an important factor affecting posttraumatic deficits in electrophysiological function, indicating a relationship between developmental status and vulnerability to mild injury. Our findings suggest that mild pediatric TBI could result in functional deficits that are more serious than currently appreciated.

Traumatic brain injury: a comparison of inpatient functional outcomes between children and adults

OBJECTIVES

To examine age-related differences in functional outcomes following traumatic brain injury. PARTICIPANTS AND PROCEDURE: Seventy-six patients admitted to a pediatric acute rehabilitation hospital were compared with 2548 adult patients in the National Institute on Disability and Rehabilitation Research-funded traumatic brain injury model systems national database.

MAIN OUTCOME MEASURES

Functional Independence Measure totals during inpatient rehabilitation.

RESULTS

Increasing age was significantly associated with improved outcome in children and with poorer outcome in adults.

CONCLUSION

The relationship between age and functional outcome is different within different age groups (pediatric vs adult), and the effect of moderating variables differs by age group.

Pediatric traumatic brain injury: quo vadis?

In this review, five questions serve as the framework to discuss the importance of age-related differences in the pathophysiology and therapy of traumatic brain injury (TBI). The following questions are included: (1) Is diffuse cerebral swelling an important feature of pediatric TBI and what is its etiology? (2) Is the developing brain more vulnerable than the adult brain to apoptotic neuronal death after TBI and, if so, what are the clinical implications? (3) If the developing brain has enhanced plasticity versus the adult brain, why are outcomes so poor in infants and young children with severe TBI? (4) What contributes to the poor outcomes in the special case of inflicted childhood neurotrauma and how do we limit it? (5) Should both therapeutic targets and treatments of pediatric TBI be unique? Strong support is presented for the existence of unique biochemical, molecular, cellular and physiological facets of TBI in infants and children versus adults. Unique therapeutic targets and enhanced therapeutic opportunities, both in the acute phase after injury and in rehabilitation and regeneration, are suggested.

History of head injury among substance users: preliminary findings

Traumatic brain injury is associated with a variety of problems in cognitive functioning that may be related to substance use and that may influence recovery. This pilot study of 591 inmates in medium and minimum-security prisons examined self-reports of head injury, mental health problems, and health service utilization in three groups: no head injury, one head injury, and two or more head injuries. The group with multiple head injuries reported significantly more emergency room visits, more hospital admission, and number of hospital stays when compared with those with no head injury. This preliminary analysis reflects a need for additional research on brain injury among substance misusers.

Survival and functional outcome of children requiring endotracheal intubation during therapy for severe traumatic brain injury

OBJECTIVE

To determine the predictors of survival and functional outcome of pediatric patients with traumatic brain injury severe enough to require endotracheal intubation and mechanical ventilation.

DESIGN

Retrospective, observational cohort study.

SETTING

Pediatric intensive care unit (ICU) at a tertiary care children's hospital.

PATIENTS

All children (n = 105) admitted over a 5-yr period with traumatic brain injury severe enough to require endotracheal intubation and mechanical ventilation. The median age was 43 months (range 1 month to 14 yrs). Of these children, 74% were male and 70% were white.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Variables studied included vital signs during the first 24 hrs of admission, Pediatric Risk of Mortality (PRISM) score, Glasgow Coma Score, duration of mechanical ventilation, and number of pediatric ICU and hospital days. Functional status was graded as normal, independent, partially dependent, or dependent in the areas of locomotion, self-care, and communication. This status was assessed at hospital discharge by chart review and at follow-up by telephone interview. The median Glasgow Coma Score was 6 (range 3 to 14) and the median PRISM score was 13 (range 1 to 51). There were 19 (18.1%) deaths, 17 in the pediatric ICU and two after hospital discharge. Of the patients who survived to hospital discharge, 39 (37.1%) patients were completely normal or independent, 42 (40%) patients were partially dependent, and seven (6.7%) patients were dependent in all three areas of function. Follow-up evaluations were available for 80 patients, with a median follow-up time of 24.5 months (range 8 to 70). Of the 78 patients who survived and were available for follow-up, the number who were functionally normal or independent increased to 69 (65.7%). At follow-up, there were eight (7.6%) patients remaining with partial dependency in at least one area of function while one (0.9%) patient continued to be dependent in all three areas of function. Mortality and dependent functional outcome were more likely in patients with younger age, lower Glasgow Coma Score, and higher PRISM score at hospital admission. Of the 27 patients with a Glasgow Coma Score of < or = 5, 11 (40.7%) survived with normal or independent functional status at follow-up. Of the 24 patients with PRISM scores of > 20, only five (20.8%) were functionally normal or independent at follow-up. The relative risk of a bad outcome for patients with a Glasgow Coma Score of < or = 5 and a PRISM score of > or = 20 was ten times higher than the group of patients with a Glasgow Coma Score of < or = 5 but a PRISM score of < 20.

CONCLUSIONS

Children with severe traumatic brain injury who survive to hospital discharge will continue to improve in their functional status over the next few years. Although low Glasgow Coma Score is strongly associated with death or poor functional outcome after therapy for traumatic brain injury, many patients with Glasgow Coma Score of < or = 5 can survive with good function. PRISM scores add to the power of Glasgow Coma Score to predict survival and functional outcome in tracheally intubated pediatric patients with Glasgow Coma Score of < or = 5.

Effect of endotracheal suctioning on the intracerebral haemodynamics of patients in fulminant hepatic failure

Fulminant hepatic failure is a severe impairment of liver function in someone who has had previously normal liver function. The patients presenting to intensive therapy units have generally had a rapid deterioration which requires prompt intervention and treatment. The first part of this paper gives a detailed review of the aetiology, physiology and management of the disease process. Medical and nursing care of these patients is critical; any adverse intervention may affect outcome. A literature review and small study of the intervention of endotracheal suctioning and its effects on intracranial pressure and cerebral perfusion pressure is described.

[Severe trauma in children]

Trauma are responsible for approximately 50% of the deaths of the pediatric population between 1-15 years of age. This high mortality rate, associated with frequent sequelae, leading sometimes to severe handicaps, is a major problem of public health in the developed countries. Pediatric trauma have some particularities, due to anatomical and physiological differences, and to specific injury mechanisms. Management of a patient with severe trauma is best performed by trained physicians, working in a multidisciplinary team with a two steps approach: 1) emergency rapid clinical assessment and resuscitation. 2) a secondary complete clinical evaluation associated with medical imaging, mainly based on CT scan. Head injuries are frequent and represent the main prognosis factor, mass lesions being less frequent and cerebral oedema more frequent in children, than in adult; brain swelling appears to be less frequent than initially reported. Management of head trauma has evolved in recent years, and is now largely directed towards the prevention of secondary ischemic brain injury: new monitoring devices are proposed to pursue that goal: transcranial doppler and continuous jugular vein oxygen saturation monitoring. Spinal cord injuries are rare but may be severe: cervical and spinal cord injuries without radiological abnormality (SC/WORA) appear to be more frequent than in adult. Most often, abdominal plain viscera injuries are treated with a conservative non operative approach. Among chest injuries, pulmonary contusion is the most frequent, with a favorable outcome in most cases within 3-4 days. Child abuse must be suspected in any case where there is no clear injury mechanism or when there is a discrepancy between the severity of the injury and the alleged mechanism.

Evidence for fluid volume depletion in hyponatraemic patients with bacterial meningitis

Since the mechanisms underlying hyponatraemia in meningitis are poorly understood, we retrospectively reviewed the records of 187 paediatric patients with bacterial meningitis treated at the Department of Pediatrics, University of Bern, Switzerland, between 1982 and 1994. The degree of dehydration calculated from naked weight on admission and at 5 days was consistently (by 2.8 x 10(-2) and significantly more pronounced in 30 hyponatraemic (plasma sodium 130 mmol l-1 or less) than in 157 normonatraemic patients (plasma sodium 131 mmol l-1 or more). Furthermore, a tendency towards reduced sodium excretion was noted in hyponatraemic patients. The results suggest that in bacterial meningitis hyponatraemia is mostly induced by clinically latent fluid volume depletion.

A clinical approach to the pharmacotherapy of aggression in children and adolescents

Overt aggression in its various forms is the most prevalent symptom presenting to pediatric mental health providers, regardless of setting. It is a behavior with a heterogeneous etiology and requires a comprehensive approach to evaluation and treatment. Evaluation of the aggressive child must assess medical, neurologic, psychiatric, psychosocial, familial, and/or educational contributions to behavioral dyscontrol. Multimodal treatment is generally required. At present, there is no single medication to recommend for the treatment of aggressive behavior. Multiple medications have clinically been used in a nonspecific fashion to target excessive childhood aggression. Although successful for some, this approach increases risk for ineffective interventions accompanied by side effects. Until a scientific understanding of the developmental neurobiology of aggression leads to more specific treatment, this review suggests the use of a diagnostic-based approach to the pharmacology of aggression (FIG. 1). Descriptive diagnostic techniques should be used to define the presence of any primary or comorbid psychiatric disorder that presents with aggression as an associated symptom. Treating aggression in the context of these psychiatric syndromes appears to be the most direct approach. Aggression occurring in the context of a medication-responsive psychiatric diagnosis appears most sensitive to pharmacologic intervention. Presently, evidence for efficacy is strongest for aggression in the context of ADHD, psychotic disorder, adolescent-onset bipolar disorder, and ictal aggression It remains less clear that medication can help aggression when it occurs independently of a pharmacologically treatable comorbid psychiatric disorder. Aggression may respond to a target symptom approach where discrete behavioral symptoms that contribute to aggression, such as irritability, explosiveness, fear, or impulsivity, may be modified by medication intervention (FIG. 1). When treatment is approached in this fashion, it is standard practice to use the least toxic and safest intervention first. Behavioral treatment based on contingency management principles could be initially recommended. Medication trials should first use medications that have demonstrated empiric efficacy in reducing aggression (TABLE 1) and that have a favorable safety profile. Neuroleptics to treat aggression in nonpsychotic psychiatrically referred youth should be kept to a minimum, secondary to their significant adverse risk profile. Alternative medications, such as selective serotonin reuptake-inhibiting antidepressants, buspirone, lithium, anticonvulsants, opiate blocking agents, propranolol, nadolol, and clonidine, deserve more clinical research in pediatric aggression. These medications may offer effective and less toxic alternatives in the pharmacologic treatment of inappropriate excessive childhood aggression.

Association between injury indices and outcome after severe traumatic brain injury in children

OBJECTIVES

(1) To determine whether indices of traumatic brain injury (TBI) in children are associated with outcome at hospital discharge and 5 to 7 years later; (2) to describe persisting disabilities.

DESIGN

Retrospective, uncontrolled study of a cohort of children with severe, nonpenetrating TBI.

SETTING

Consecutive admissions to a level 1 trauma center over 2 years.

SUBJECTS

Seventy-five children younger than 17 years old were previously studied to identify predictors of disability at acute care discharge. Thirty-three of the 50 survivors (66%) were enrolled.

MAIN OUTCOME MEASURES

A database of variables abstracted from medical records was available from the previous study. Subjects were surveyed about premorbid problems, school, employment, and current function, and school records were reviewed. Using all information, a Glasgow Outcome Scale (GOS) score was assigned 5 to 7 years after TBI. Associations between database variables and GOS score at discharge and follow-up were examined using nonparametric analyses. The odds ratio for good recovery was calculated for all significant associations.

RESULTS

Late GOS was good recovery for 27%, moderate disability for 55%, and severe disability for 18%. Discharge GOS scores were related (p < or = .01) to the head Abbreviated Injury Scale score, Injury Severity Scale score, Glasgow Coma Scale (GCS) score measured in the field and at 6, 24, and 72 hours, the length of coma, and initial discharge site. Late GOS scores were related (p < or = .01) to the same variables except the field and 6-hour GCS scores, as well as pupillary responses in the field and the discharge GOS. At follow-up, 64% were independent in mobility, 70% in self-care, and 24% in cognitive items on the Functional Independence Measure. Seventy percent of children received special education services. Employment histories were poor. Most subjects were not receiving neurological or rehabilitation follow-up.

CONCLUSIONS

Early and late outcome after severe TBI are related to variables measured at and after injury. Subjects had long-term educational and vocational problems but often did not utilize the medical model of neurorehabilitation.

Short- and long-term prognostic value of the electroencephalogram in children with severe head injury

To determine the prognostic value of the EEG in severely head-injured children, 24 patients were studied for 8-36 months. During coma, 4 EEG patterns were found: borderline, sleep-like, changeable and slow monotonous (SM). For the short-term prognosis, we conclude that the SM pattern (12/24 patients) indicates a bad prognosis because it was associated with a longer coma and awakening period than that of other EEG patterns and because it was observed in the 3 patients who died from brain injury. In contrast, we describe a 'prewake' pattern (11/22 survivors) which, when it occurs, always announces the onset of a complete awakening. For the long-term prognosis, only 50% of the survivors who had an SM pattern during coma have as good an intellectual and motor outcome as the survivors who displayed other EEG patterns. No other EEG features recorded during coma have short- or long-term prognostic significance.

Clinicoradiological and therapeutic considerations in severe diffuse traumatic brain injury in children

Forty-one children with severe head injuries and diffuse brain lesions were selected from a consecutive series of 62 children in traumatic coma (21 focal mass lesions) and studied. According to the CT pattern, two main types of intracranial lesions were considered: diffuse axonal injury (DAI) and diffuse brain swelling (DBS). High mortality, due to secondary increases of intracranial pressure (ICP), correlated well with the patterns of severe DBS, absence of perimesencephalic cisterns, and obliteration of the ventricles. However, children with normal CTs, and/or obvious shearing injuries indicative of DAI, had favorable outcomes; there was no mortality if increased ICP was not present. We conclude that although there does not seem to be any routine indications for ICP monitoring in children with pure DAI, early ICP monitoring and aggressive management of increasing ICP should be considered in comatose children with DBS, especially when associated with subarachnoid hemorrhage and respiratory or circulatory failure.

The admission cardiorespiratory performance in relation to outcome in pediatric ICU patients

We tested the hypothesis that the admission cardiorespiratory performance determines the outcome in pediatric intensive care unit (PICU) patients. We studied 331 patients who were assigned to one of the three commonly encountered PICU clinical entities: respiratory disease, cardiovascular disease and head trauma. All patients were evaluated by a simple cardiorespiratory scoring system which we named "Rule of 60" (RO60), and their highest score within the first 24 h of arrival in the PICU was used for the study. This scoring system includes 6 cardiorespiratory parameters where a value of 60 represents a cut-off point above or below which 0 points (low risk) or 10 points (high risk) are assigned. The relationship between score and mortality rate revealed that the higher the score the higher is the mortality rate. We determined two categories of severity of illness in our patients. Patients at severity level A had scores ranging from 0 through 30 and the mortality rate in this category ranged from 2% to 5%. Patients at severity level B had scores ranging from 40 through 60 and had a higher mortality rate: 30% to 80%. The overall mortality rates for patients at severity level A and B were 2% and 54% respectively. Patients with respiratory disease at severity level B had the lowest mortality rate (20%), whereas patients with cardiovascular disease and head trauma had mortality rates of 52% and 80% respectively. We found that our cardiorespiratory scoring system was as good as the Glasgow Coma Scale for indicating prognosis and outcome in head trauma patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Head trauma in the child

Head injury, either alone or in combination with multiple injuries, is common in children. Its pattern is different in children compared to adults, with diffuse cerebral swelling rather than localized hematoma being most common. The pathophysiology of pediatric head trauma is not yet clearly elucidated, but may be closely related to changes in the regulation of cerebral blood flow. The initial management and subsequent care of the child with severe brain injury are discussed from a multisystem viewpoint. The prognosis for children with severe head injury seems brighter than for adults, but there are not yet enough data to allow prediction of outcome in any individual case. Efforts to prevent, rather than treat, head injury in childhood are more likely to be beneficial.

Outcome from severe head injury in children and adolescents

A consecutive series of 37 children (17 years old and under) with severe head injury is presented. The data confirm that morbidity and mortality are lower in children than in adults: 51% of these young patients had a good recovery or moderate disability at 6 months. The mortality rate in this series (33%) is higher than in some reports, but probably more closely approximates the death rate from these injuries in an unselected pediatric population than do statistics from tertiary care hospitals. There was no significant relationship between age and outcome in this age group, but mass lesions and uncontrolled intracranial hypertension adversely affected outcome. Diffuse cerebral swelling was commonly seen on computerized tomography scans, and generally was associated with a satisfactory outcome (75%). Two of 13 deaths were considered preventable, emphasizing the narrow therapeutic safety margin and extreme care required in treating these patients.

Intensive care after fresh water immersion accidents in children

Six children who remained in deep coma after immersion accidents in fresh water received therapy to maintain normal intracranial pressure (ICP). This involved controlled ventilation to ensure hypocapnia and hyperoxaemia, maintenance of low normothermia, fluid restriction, dexamethasone (1-1.5 mg/kg initially, 1-1.5 mg/kg/day as maintenance) and barbiturates (phenobarbitone and thiopentone). The latter were given in a wide range of dosage. Increased ICP was common to all patients, but could always be kept at acceptable levels. All patients suffered from pulmonary oedema; three developed broncho-pneumonia and two developed adult respiratory distress syndrome. All children survived with good recovery, two needed active rehabilitation for several months.