Pediatric Head Trauma

Variability in Standardized Mortality Rates Among Pediatric Traumatic Brain Injury Patients: A Comparative Analysis of Trauma Centers

INTRODUCTION

Traumatic brain injury (TBI) causes significant morbidity and mortality in pediatric patients and care is highly variable. Standardized mortality ratio (SMR) summarizes the mortality rate of a specific center relative to the expected rates across all centers, adjusted for case-mix. This study aimed to evaluate variations in SMRs among pediatric trauma centers for TBI.

METHODS

Patients aged 1-18 diagnosed with TBI within the National Trauma Data Bank (NTDB) from 2017 to 2019 were included. Center-specific SMRs and 95% confidence intervals identified centers with mortality rates significantly better or worse than the median SMR for all centers.

RESULTS

316 centers with 10,598 patients were included. SMRs were risk-adjusted for patient risk factors. Unadjusted mortality ranged from 16.5 to 29.5%. Three centers (1.5%) had significantly better SMR (SMR <1) and three centers (1.5%) had significantly worse SMR (SMR >1). Significantly better centers had a lower proportion of neurosurgical intervention (2.4% vs. 11.8%, p < 0.001), a higher proportion of supplemental oxygen administration (93.7% vs. 83.5%, p = 0.004) and venous thromboembolism prophylaxis (53.2% vs. 40.6%, p < 0.001) compared to significantly worse centers.

CONCLUSIONS

This study identified centers that have significantly higher and lower mortality rates for pediatric TBI patients relative to the overall median rate. These data provide a benchmark for pediatric TBI outcomes and institutional quality improvement.

LEVEL OF EVIDENCE

Level III.

TYPE OF STUDY

Retrospective Comparative Study.

[Prehospital care of pediatric traumatic brain injury]

BACKGROUND

Traumatic brain injury (TBI) in children and adolescents is associated with significant morbidity and, in severe TBI, mortality. The aim of this article is to provide an overview of the spectrum of TBI, its pathophysiology, and current treatment recommendations for prehospital management of children and adolescents with TBI.

MATERIALS AND METHODS

The current literature was reviewed for studies on the management of TBI in children and adolescents.

RESULTS

In recent years, a large number of scientific studies have been published that have resulted in evidence-based guidelines for primary care of children with TBI. The primary aim is to minimize secondary brain damage following TBI, for which immediate assessment of the severity of TBI at the scene based on clinical findings and the accident mechanism and initiation of specific treatment measures to prevent hypoxia, hypotension, and hypothermia are critical. Not only prehospital management, but also the rapid transfer of children with severe TBI to centers with high neurosurgical, pediatric surgical, and pediatric intensive care expertise is of particular importance to improve survival and neurological outcome after severe TBI.

CONCLUSION

Structured prehospital management may help reduce secondary brain injury after TBI and lead to improved clinical outcomes.

Measuring Energy Requirements of Traumatic Brain Injury Patients in Pediatric Intensive Care With Indirect Calorimetry: A Comparison With Empiric Methods

OBJECTIVES

Energy requirements following moderate or severe pediatric traumatic brain injury (TBI) have not been fully elucidated. Indirect calorimetry (IC) is the gold standard for measuring resting energy expenditure (MREE) in PICU. However, technical complexity limits its use. We aimed to determine whether MREE differs from standard of care energy estimation and delivery in a cohort of pediatric patients following moderate to severe TBI during PICU admission.

DESIGN

Retrospective case series study.

SETTING

Single-center, 16-bed general PICU in Canada between May 2011 and January 2019.

PATIENTS

Children (0-18 yr) admitted to a PICU for moderate (Glasgow Coma Scale [GCS] 9-12) to severe TBI (GCS < 9) and had an IC study performed while mechanically ventilated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, 245 patients were admitted with the diagnosis of trauma with TBI. The study includes a convenience sample of 26 patients with severe ( n = 23) and moderate ( n = 3) TBI who underwent a total of 34 IC measurements. MREE varied considerably from 29% to 144% of predicted energy expenditure. Using Bland-Altman comparative analysis, neither Schofield nor World Health Organization predictive equations were in agreement with MREE. Only one measurement revealed that the patient was appropriately fed (energy provided in nutrition support was within 10% of MREE); 10 (38%) measurements revealed overfeeding and 15 (58%) underfeeding at the time of testing.

CONCLUSIONS

The present study adds to the small body of literature highlighting the limitations of predictive equations to evaluate energy requirements following moderate to severe pediatric TBI. IC, when feasible, should be used as the preferred method to orient PICU teams to feed such vulnerable patients.

SARS-CoV-2-Associated Multisystem Inflammatory Syndrome in Children (MIS-C): A Case Report from Iraq

The novel coronavirus disease (COVID-19) continues to evolve. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-associated multisystem inflammatory syndrome in children (MIS-C) is a rare post-COVID-19 complication that affects children with critical outcomes. Few MIS-C reports were available from Arab-Asian ethnicities. We here describe a presentation mimicking a head injury overlapping the manifestations of MIS-C in a child from Iraq. A 10-year-old boy presented with blunt trauma in a shock-like status, and a head injury was suspected. Since he was febrile two days before the trauma, another pathology was assumed. Imaging and laboratory evaluations were performed, and after excluding gross neurosurgical etiology, he was initially treated as a toxic shock syndrome. Meanwhile, he was deteriorating with continuous fever, impaired consciousness, and seizure on the following day. Although not considered initially, close monitoring with a multidisciplinary approach and serial investigations revealed that the child met the criteria of MIS-C. SARS-CoV-2 IgG was shown to be high, while the RT-PCR of COVID-19 was negative. Once he received immunoglobulin and methylprednisolone, he improved dramatically. In conclusion, this report aimed to increase awareness about MIS-C among health workers and emphasized the need for a multidisciplinary team approach in Iraq due to the importance of timely treatment.

Age predicts likelihood for surgery for pediatric tbi: an analysis of 1745 hospitlizations from a Chinese Children's Hospital

PURPOSE

We tested the role of age and sex in surgery following pediatric TBI hospitalization.

METHODS

Records of 1745 children hospitalized at a pediatric neurotrauma center in China included age, sex, cause of injury, diagnosis of injury, days of hospitalization, in-house rehabilitation, Glasgow Coma Scale score, mortality, 6-month post-discharge Glasgow Outcome Scale score, and surgery intervention. The children were 0-13 years (M= 3.56 years; SD = 3.06), with 47.4% 0-2 years of age.

RESULTS

The mortality rate was 1.49%. Logistic regression on 1027 children with epidural hematoma, subdural hematoma, intracerebral hemorrhage, and intraventricular hemorrhage showed that controlling for other variables, the odds for younger children to receive surgery was statistically lower for epidural hematomas (OR = 0.75; 95% CI = 0.68-0.82), subdural hematomas (OR = 0.59; 95% CI = 0.47-0.74), and intraventricular hemorrhage (OR = 0.52; 95% CI = 0.28-0.98).

CONCLUSIONS

While severity of TBI and type of TBI were expected predictors for surgery, a younger age also predicted a significantly lower likelihood of surgery in our sample. Sex of the child was unrelated to surgical intervention.

History of pediatric TBI hospitalization and current child-parent relationship quality in China

BACKGROUND

Long-term child-parent relationship quality following hospitalization for pediatric traumatic brain injury (TBI) remains poorly understood.

OBJECTIVE

We tested whether current child-parent conflict and closeness were related to the children's history of TBI-related experiences and contemporary child/family characteristics.

METHODS

The sample included 202 Chinese children (Boys: 60.4%) with a history of hospitalization for TBI. On average, the children were 11.2 years old (SD = 1.59) and sustained TBI at 8.5 years old (SD = 1.6). TBI-related data were obtained from hospital medical records. Parents provided data on child-parent closeness, child-parent conflict, and parental efficacy 2-4 years (M = 2.7, SD = 0.7) after discharge.

RESULTS

Forty-nine children (24.3%) had mild TBI, 139 (68.8%) had moderate TBI, and 14 (6.9%) had severe TBI. Surgical intervention occurred among 128 (63.4%) of the 202 children. Contemporaneous child and family characteristics explained 19% of the variance, history of surgery, length of hospitalization, and recovery status explained another 7%, and the interaction between length of hospitalization and parental efficacy explained another 4% in child-parent conflict. Contemporaneous child and family characteristics explained 29% of the variance, and TBI-related variables explained another 2% in child-parent closeness.

CONCLUSION

Post-TBI child-parent relationship was more associated with child/family characteristics than with TBI variables. Practitioners and families should be aware of the long-term challenges to child-parent relationship following hospitalization for pediatric TBI.

Impact of the COVID-19 pandemic on pediatric emergency department utilization for head injuries

Head injuries are a leading cause of death and disability in children, accounting for numerous emergency department (ED) visits. It is unclear how the COVID-19 pandemic has influenced healthcare utilization for pediatric head injuries. We hypothesize that the proportion of ED visits attributable to head injury and severity will increase during the COVID-19 era. Retrospective study using electronic health record data to compare proportion and severity of head injury for children 0-21 years of age from three urban mid-Atlantic EDs in the pre-COVID-19 era (March-June 2019) and COVID-19 era (March-June 2020). Controlling for confounders, logistic regression analyses assessed ORs of head injury outcomes. The χ2 analyses identified differences in patient characteristics. The proportion of head injury visits within the ED population significantly increased during the COVID-19 era (adjusted OR (aOR)=1.2, 95% CI 1.1 to 1.4). Proportion of visits requiring hospitalization for head injury increased by more than twofold in the COVID-19 era (aOR=2.3, 95% CI 1.3 to 4.3). Use of head CT imaging did not significantly change in the COVID-19 era (aOR=1.0, 95% CI 0.7 to 1.6). The proportion of ED visits and hospitalizations for head injury increased during the COVID-19 era. This could be due to changes in the level of supervision and risk exposures in the home that occurred during the pandemic, as well as differences in postinjury care, level of awareness regarding injury severity, and threshold for seeking care, all of which may have influenced pediatric healthcare utilization for head injuries.

Management of Severe Traumatic Brain Injury in Pediatric Patients

The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.

Pediatric traumatic brain injury: a new relation between outcome and neutrophil-to-lymphocite ratio

Leading causes of death in industrialized countries are traumatic injuries and acquired disability, and entry to the emergency department in childhood. TBI (traumatic brain injury) may involve the onset of both primary lesions and a complex immune response (sterile immune reaction to brain injury), which, in addition to neuro-protective effects, can mediate secondary neurological injury. The neutrophil-to-lymphocyte ratio (NLR), as a circulating inflammatory marker, has been related to outcomes in adult patients with non-neurologic diseases (such as gut tumours) or neurologic diseases (such as stroke or brain tumours), and to the prognosis of traumatic brain injury in adolescents and adults. However, the potential role of NLR in predicting outcomes in paediatric head trauma is not clearly defined. The aim of this retrospective observational study is to evaluate the association between clinical features predictive of intracranial and extracranial lesions in TBI and NLR and to establish whether an elevation of NLR is indirectly associated with adverse outcomes in pediatric patients with TBI. We analysed a sample of 219 pediatric patients, between 2-18 years old, after a TBI, and evaluated if differences in NLR were associated with neurological signs or positive CT in pediatric patients. We then compared the NLR values between healthy subjects and patients with TBI. (www.actabiomedica.it)

Paediatric patients in mass casualty incidents: a comprehensive review and call to action

The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

Pediatric Mild Traumatic Brain Injury: Who Can Be Managed at a Non-pediatric Trauma Center Hospital? A Systematic Review of the Literature

BACKGROUND

Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.

METHODS

A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.

RESULTS

Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.

CONCLUSIONS

An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.