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Castro M, Agoubi LL, Velonjara J, Lutkevicius C, Guadagnoli N, Lujan S, Petroni G, Bell MJ, Vavilala MS, Mock C. Clinical Epidemiology of Extracranial Injuries in Severe Pediatric Traumatic Brain Injury in South America. Injury 2024; 55:111394. [PMID: 38360517 PMCID: PMC11046303 DOI: 10.1016/j.injury.2024.111394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/10/2024] [Accepted: 01/27/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) is a leading cause of pediatric mortality, with a disproportionate burden on low- and middle-income countries. The impact of concomitant extracranial injury (ECI) on these patients remains unclear. This study is the first to characterize the epidemiology and clinical course of severe pediatric TBI with extracranial injuries in any South American country. METHODS We conducted a secondary analysis of baseline data collected prior to implementation of a clinical trial on TBI care in Argentina, Paraguay, and Chile from September 2019 to July 2020. Patients ≤18 years with CT evidence of TBI, and a Glasgow coma scale (GCS) score ≤8 were recruited. Patients were initially stratified by highest non-head abbreviated injury scale (AIS): isolated TBI (AIS=0), minor extracranial injury (MEI; AIS=1-2), and serious extracranial injury (SEI; AIS≥3). Patients were subsequently stratified by mechanism of injury. Intergroup differences were compared using ANOVA, two-tailed unpaired t-tests, and chi-square tests. RESULTS Among the 116 children included, 33 % (n = 38) had an isolated TBI, 34 % (n = 39) had MEI, and 34 % (n = 39) had SEI. Facial (n = 53), thoracic (n = 44), and abdominal (n = 31) injuries were the most common ECIs. At discharge, there were no significant differences in median GCS, GOS, or GOS-extended between groups. Patients with SEI had a longer hospital LOS than those with isolated TBI (median 28.0 (IQR 10.6-40.1) vs 11.9 (IQR 8.7-20.7) days, p = 0.013). The most common mechanisms of injury were road traffic injuries (RTIs) (n = 50, 43 %) and falls (n = 35, 30 %). Patients with RTI-associated TBIs were more likely to be older (median 11.0 (IQR 3.0-14.0) vs 2.0 (IQR 0.8-7.0) years, p<0.001) and more likely to have an ECI (86% vs 54 %, respectively; p = 0.003). ICU and Hospital LOS for RTI patients (median 10.5 (IQR 6.1-21.1) and 24.1 (IQR 11.5-40.4) days) were longer than those of fall patients (median 6.1 (IQR 2.6-8.9) and 13.7 (IQR 7.7-24.5) days). CONCLUSIONS Extracranial injuries are common in South American patients with severe TBI. Severe ECI is more frequently associated with RTIs and can result in a higher rate of surgical procedures and LOS. Further strategies are needed to characterize the prevention and treatment of severe pediatric TBI in the South American context.
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Affiliation(s)
- Miguel Castro
- Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, FL, USA; Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Lauren L Agoubi
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA.
| | - Julia Velonjara
- Harborview Injury Prevention and Research Center, Seattle, WA, USA; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Silvia Lujan
- Centro de Informática e Investigación Clínica, Rosario, Argentina
| | - Gustavo Petroni
- Centro de Informática e Investigación Clínica, Rosario, Argentina
| | - Michael J Bell
- Children's National Hospital Critical Care Medicine, Washington, DC, USA
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Seattle, WA, USA; Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Charles Mock
- Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA; Harborview Injury Prevention and Research Center, Seattle, WA, USA
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Rosenberg A, Wojick M, Asay B, Williams K, Wolfe L, Baghdassarian A, Umuhoza C, Ntaganda E, Kabagema I, Uwitonze JM, Dushime T, Jayaraman S. Developing Sustainable Prehospital Pediatric Care in Rwanda. Pediatr Emerg Care 2022; 38:224-227. [PMID: 35482495 DOI: 10.1097/pec.0000000000002699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Unintentional injury is the leading cause of death in children older than 1 year and disproportionately affects pediatric patients in low- and middle-income countries.Improved prehospital care capacity has demonstrated the ability to improve care and save lives. Our collaboration developed and implemented a sustainable prehospital emergency pediatrics care course (EPCC) for Service d'Aide Medicale Urgente, the public emergency medical service in Rwanda. METHODS A 1-day context-specific EPCC was developed based on international best practices and local feedback. Two cohorts were created to participate in the course. The first group, EPCC 1, was made of 22 Service d'Aide Medicale Urgente providers with preexisting knowledge on the topic who participated in the course and received training to lead future sessions. After completion of the EPCC1, this group led the second cohort, EPCC 2, which was composed of 26 healthcare providers from around Rwanda. Each group completed a 50 question assessment before and after the course. RESULTS Emergency pediatrics care course 1 mean scores were 58% vs 98% (pre vs post), EPCC 2 mean scores were 49% vs 98% (pre vs post), using matched-pair analysis of 22 and 32 participants, respectively. When comparing unequal variances across the groups with a 2-tailed paired t test, EPCC 1 and EPCC 2 had a statistically significant mean change in pretest and posttest assessment test scores of 40% compared with 46%, P < 0.0001, with 95% confidence interval. A 1-way analysis of variance mean square analysis for the change in scores showed that regardless of the baseline level of training for each participant, all trainees reached similar postassessment scores (F(1) = 1.45, P = 0.2357). CONCLUSIONS This study demonstrates effective implementation of a context-appropriate prehospital pediatric training program in Kigali, Rwanda. This program may be effective to support capacity development for prehospital care in Rwanda using a qualified local source of instructors.
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Affiliation(s)
- Ashley Rosenberg
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
| | - Megan Wojick
- Virginia Commonwealth University School of Medicine
| | | | - Kenneth Williams
- Center for Trauma and Critical Care Education, Department of Surgery, Virginia Commonwealth University
| | - Luke Wolfe
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
| | - Aline Baghdassarian
- Department of Pediatric Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Edmond Ntaganda
- Department of Pediatrics, University Teaching Hospital of Kigali
| | - Ignace Kabagema
- Service d'Aide Medicale Urgente, Rwanda Ministry of Health, Kigali, Rwanda
| | | | - Theophile Dushime
- Service d'Aide Medicale Urgente, Rwanda Ministry of Health, Kigali, Rwanda
| | - Sudha Jayaraman
- From the Division of Acute Care Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine
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Wang Z, Nguonly D, Du RY, Garcia RM, Lam SK. Pediatric traumatic brain injury prehospital guidelines: a systematic review and appraisal. Childs Nerv Syst 2022; 38:51-62. [PMID: 34557952 DOI: 10.1007/s00381-021-05364-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 09/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) disproportionately affects children within low- and middle-income countries (LMICs). Prehospital emergency care can mitigate secondary brain injury and improve outcomes. Here, we systematically review clinical practice guidelines (CPGs) for pediatric TBI with the goal to inform LMICs prehospital care. METHODS A systematic search was conducted in PubMed/Medline, Embase, and Web of Science databases. We appraised evidence-based CPGs addressing prehospital management of pediatric TBI using the Appraisal of Guidelines for Research & Evaluation (AGREE) tool. CPGs were rated as high-quality if ≥ 5 (out of 6) AGREE domains scored > 60%. RESULTS Of the 326 articles identified, 10 CPGs were included in analysis. All 10 were developed in HICs, and 4 were rated as high-quality. A total of 154 pediatric prehospital recommendations were grouped into three subcategories, initial assessment (35.7%), prehospital treatment (38.3%), and triage (26.0%). Of these, 79 (51.3%) were evidence-based with grading, and 31 (20.1%) were consensus-based without direct evidence. CONCLUSION Currently available CPGs for prehospital pediatric TBI management were all developed in HICs. Four CPGs have high-quality, and recommendations from these can serve as frameworks for LMICs or resource-limited settings. Context-specific evaluation and implementation of evidence-based recommendations allow LMIC settings to respond to the public health crisis of pediatric TBI and address gaps in trauma care systems.
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Affiliation(s)
- Zhe Wang
- Department of Neurological Surgery, Stony Brook University Renaissance School of Medicine, Health Science Center T12, Room 080, 100 Nicolls Rd, Stony Brook, NY, 11790, USA.
| | - Dellvin Nguonly
- Department of Emergency Medicine, Rocky Vista University College of Osteopathic Medicine, Parker, CO, USA
| | - Rebecca Y Du
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Roxanna M Garcia
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sandi K Lam
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
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Lumba-Brown A, Prager EM, Harmon N, McCrea MA, Bell MJ, Ghajar J, Pyne S, Cifu DX. A Review of Implementation Concepts and Strategies Surrounding Traumatic Brain Injury Clinical Care Guidelines. J Neurotrauma 2021; 38:3195-3203. [PMID: 34714147 DOI: 10.1089/neu.2021.0067] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite considerable efforts to advance the science surrounding traumatic brain injury (TBI), formal efforts supporting the current and future implementation of scientific findings within clinical practice and healthcare policy are limited. While many and varied guidelines inform the clinical management of TBI across the spectrum, clinicians and healthcare systems are not broadly adopting, implementing, and/or adhering to them. As part of the Brain Trauma Blueprint TBI State of the Science, an expert workgroup was assembled to guide this review article, which describes: (1) possible etiologies of inadequate adoption and implementation; (2) enablers to successful implementation strategies; and (3) strategies to mitigate the barriers to adoption and implementation of future research.
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Affiliation(s)
- Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University, Stanford, California, USA
| | | | | | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Neurosurgery Research Laboratory, Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Michael J Bell
- Pediatrics, Critical Care Medicine, Children's National Hospital, Washington DC, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Scott Pyne
- Traumatic Brain Injury Center of Excellence, Defense Health Agency, Silver Spring, Maryland, USA
| | - David X Cifu
- Virginia Commonwealth University School of Medicine, and Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia, USA
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The Status of Quality Improvement Programs for Pediatric Traumatic Brain Injury Care in Argentina. J Surg Res 2021. [PMID: 33892460 PMCID: PMC8238872 DOI: 10.1016/j.jss.2021.03.024;] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America. METHODS We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test. RESULTS Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities. CONCLUSIONS Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.
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Lujan S, Petroni G, Castellani P, Bollada S, Bell MJ, Velonjara J, Vavilala MS, Mock C. The Status of Quality Improvement Programs for Pediatric Traumatic Brain Injury Care in Argentina. J Surg Res 2021; 265:71-78. [PMID: 33892460 DOI: 10.1016/j.jss.2021.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America. METHODS We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test. RESULTS Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities. CONCLUSIONS Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data.
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Affiliation(s)
- Silvia Lujan
- Centro de Informática e Investigación Clínica (CIIC), Rosario, Sante Fe, Argentina
| | - Gustavo Petroni
- Centro de Informática e Investigación Clínica (CIIC), Rosario, Sante Fe, Argentina
| | - Pablo Castellani
- Hospital del Niños Sor María Ludovica, La Plata, Provincia de Buenos Aires, Argentina
| | - Sabrina Bollada
- Hospital Interzonal del Niños Eva Perón, Catamarca, Argentina
| | | | - Julia Velonjara
- Harborview Injury Prevention and Research Center, Box 359960, Harborview Medical Center, Seattle, Washington
| | - Monica S Vavilala
- Harborview Injury Prevention and Research Center, Box 359960, Harborview Medical Center, Seattle, Washington
| | - Charles Mock
- Harborview Injury Prevention and Research Center, Box 359960, Harborview Medical Center, Seattle, Washington.
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Wooldridge G, Hansmann A, Aziz O, O'Brien N. Survey of resources available to implement severe pediatric traumatic brain injury management guidelines in low and middle-income countries. Childs Nerv Syst 2020; 36:2647-2655. [PMID: 32300872 DOI: 10.1007/s00381-020-04603-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/30/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of death and disability worldwide, with a disproportionately high burden in low-middle income countries. Guideline implementation has been associated with mortality reduction in high-income countries (HIC), but it is not known if hospitals in low and middle-income countries possess the resources to implement the pre-hospital TBI guidelines and the guidelines for the management of severe pediatric traumatic brain injury. METHOD An anonymous online survey was undertaken by a range of health care professionals currently managing children with severe TBI in low to middle-income countries. A variety of international and national pediatric, intensive care, and neurological societies assisted in the survey distribution. Thirty-eight questions were included to evaluate patient care and the provider's perceptions of their resources available to implement the pre-hospital specific TBI and current pediatric severe TBI guidelines. RESULTS Two hundred and forty-seven hospitals were represented from 68 countries. Fifty percent of LMIC hospitals that responded had the resources to implement 13 of 15 guidelines for the pediatric component of pre-hospital management for TBI and all baseline care recommendations. First tier therapies including the intracranial pressure (ICP) and cerebral perfusion pathways (CPP), however, demonstrated low capacity for uptake with 21.5% and 38.5% of surveyed hospitals possessing sufficient resources to follow the recommended pathways. CONCLUSION Pediatric TBI ICP/CPP management guidelines require numerous resources not widely sourced in LMIC. The creation of international guidelines that outline recommendations of care for LMIC may benefit patient care and outcomes in these settings.
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Affiliation(s)
| | | | - Omer Aziz
- Bristol Royal Hospital for Children, Bristol, UK
| | - Nicole O'Brien
- Queen Elizabeth Central Hospital, Blantyre, Malawi.,Nationwide Children's Hospital, Columbus, OH, USA
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Dixon J, Comstock G, Whitfield J, Richards D, Burkholder TW, Leifer N, Mould-Millman NK, Calvello Hynes EJ. Emergency department management of traumatic brain injuries: A resource tiered review. Afr J Emerg Med 2020; 10:159-166. [PMID: 32923328 PMCID: PMC7474234 DOI: 10.1016/j.afjem.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/05/2020] [Accepted: 05/20/2020] [Indexed: 11/12/2022] Open
Abstract
Introduction Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma. Objectives Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework. Methods A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings. Key recommendations Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.
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Dara PK, Parakh M, Choudhary S, Jangid H, Kumari P, Khichar S. Clinico-radiologic Profile of Pediatric Traumatic Brain Injury in Western Rajasthan. J Neurosci Rural Pract 2019; 9:226-231. [PMID: 29725174 PMCID: PMC5912029 DOI: 10.4103/jnrp.jnrp_269_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objective: The aim of this study was to evaluate clinico-radiological profile and outcome of pediatric traumatic brain injury (TBI). Design: Prospective observational study Setting: Intensive Care Unit, ward and OPD of Pediatrics, Dr. S. N. Medical College, Jodhpur (tertiary care hospital). Participants: A total of 188 children (1 month–18 years) were enrolled and 108 admitted. Intervention: TBI classified as mild, moderate, or severe TBI. Neuroimaging was done and managed as per protocol. Demographic profile, mode of transport, and injury were recorded. Outcome: Measured as hospital stay duration, focal deficits, mortality, and effect of early physiotherapy. Results: Males slightly outnumbered females mean age was 5.41 ± 4.20 years. Fall from height was the main cause of TBI (61.11%) followed by road traffic accident (RTA) (27.78%). Majority (56.56%) reached hospital within 6 h of injury, out of which 27% of patients were unconscious. Mild, moderate, and severe grade of TBI was seen in 50%, 27.78%, and 22.22% of cases, respectively. About 12.96% of cases required ventilator support. The average duration of hospital stay was 11.81 ± 12.9 days and was lesser when physiotherapy and rehabilitation were started early. In all children with temporal bone fracture, magnetic resonance imaging (MRI) brain revealed a temporal lobe hematoma and contusion in spite of initial computed tomography (CT) head normal. Children who have cerebrospinal fluid (CSF) rhinorrhea/otorrhea had a high chance of fracture of base of skull and contusion of the basal part of the brain. Conclusion: In India, fall from height is common setting for pediatric TBI besides RTA. Early initiation of physiotherapy results in good outcome. MRI detects basal brain contusions in children presenting with CSF rhinorrhea/otorrhea even if initial CT brain is normal.
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Affiliation(s)
- Pawan Kumar Dara
- Department of Pediatrics, S P Medical College, Bikaner, Rajasthan, India
| | - Manish Parakh
- Department of Pediatrics, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - Shyama Choudhary
- Department of Pediatrics, Dr. S. N. Medical College, Jodhpur, Rajasthan, India
| | - Hemant Jangid
- Department of Radiodiagnosis, MDM Hospital, Jodhpur, Rajasthan, India
| | - Priyanka Kumari
- Department of Anaesthesia, S P Medical College, Bikaner, Rajasthan, India
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Traumatic Brain Injury and Infectious Encephalopathy in Children From Four Resource-Limited Settings in Africa. Pediatr Crit Care Med 2018; 19:649-657. [PMID: 29664874 DOI: 10.1097/pcc.0000000000001554] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the frequency, interventions, and outcomes of children presenting with traumatic brain injury or infectious encephalopathy in low-resource settings. DESIGN Prospective study. SETTING Four hospitals in Sub-Saharan Africa. PATIENTS Children age 1 day to 17 years old evaluated at the hospital with traumatic brain injury or infectious encephalopathy. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We evaluated the frequency and outcomes of children presenting consecutively over 4 weeks to any hospital department with traumatic brain injury or infectious encephalopathy. Pediatric Cerebral Performance Category score was assessed pre morbidity and at hospital discharge. Overall, 130 children were studied (58 [45%] had traumatic brain injury) from hospitals in Ethiopia (n = 51), Kenya (n = 50), Rwanda (n = 20), and Ghana (n = 7). Forty-six percent had no prehospital care, and 64% required interhospital transport over 18 km (1-521 km). On comparing traumatic brain injury with infectious encephalopathy, there was no difference in presentation with altered mental state (80% vs 82%), but a greater proportion of traumatic brain injury cases had loss of consciousness (80% vs 53%; p = 0.004). Traumatic brain injury patients were older (median [range], 120 mo [6-204 mo] vs 13 mo [0.3-204 mo]), p value of less than 0.001, and more likely male (73% vs 51%), p value of less than 0.01. In 78% of infectious encephalopathy cases, cause was unknown. More infectious encephalopathy cases had a seizure (69% vs 12%; p < 0.001). In regard to outcome, infectious encephalopathy versus traumatic brain injury: hospital lengths of stay were longer for infectious encephalopathy (8 d [2-30 d] vs 4 d [1-36 d]; p = 0.003), discharge rate to home, or for inpatient rehabilitation, or death differed between infectious encephalopathy (85%, 1%, and 13%) and traumatic brain injury (79%, 12%, and 1%), respectively, p value equals to 0.044. There was no difference in the proportion of children surviving with normal or mild disability (73% traumatic brain injury vs 79% infectious encephalopathy; p = 0.526). CONCLUSIONS The epidemiology and outcomes of pediatric traumatic brain injury and infectious encephalopathy varied by center and disease. To improve outcomes of these conditions in low-resource setting, focus should be on neurocritical care protocols for pre-hospital, hospital, and rehabilitative care.
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Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group. PLoS One 2017; 12:e0189296. [PMID: 29244842 PMCID: PMC5731744 DOI: 10.1371/journal.pone.0189296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 11/24/2017] [Indexed: 02/01/2023] Open
Abstract
Objective Little is known about the critical care management of children with traumatic brain injury (TBI) in low middle income countries. We aimed to identify indicators of intensive care unit (ICU) treatments associated with favorable outcomes in Argentine children with severe TBI. Methods We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with severe TBI who were admitted to an ICU in one of the seven study centers. Severe TBI was defined by head AIS ≥ 3, head CT with traumatic lesion, and admission GCS < 9. Seven indicators of best practice TBI care were examined. The primary outcome was discharge Pediatric Cerebral Performance Category Scale [PCPC] and Pediatric Overall Performance category Scale [POPC]. We also examined variation in ICU care and in-patient mortality. Results Of the 117 children, 67% were male and 7.5 (4.3) years on average, 92% had isolated TBI. Hypotension (54%) was more common than hypoxia (28%) and clinical or radiographic signs of high intracranial pressure (ICP) were observed in 92%. Yet, ICP monitoring occurred in 60% and hyperosmolar therapy was used in only 36%. Adherence to indicators of best TBI practice ranged from 55.6% to 83.7% across the seven centers and adherence was associated with favorable discharge PCPC (aRR 0.98; 95% CI [0.96, 0.99]), and POPC (aRR 0.98; 95% CI [0.96, 0.99]). Compared to patients whose adherence rates were below 65%, patients whose adherence rates were higher between 75%-100% had better discharge PCPC (aRR 0.28; 95% CI [0.10, 0.83]) and POPC (aRR 0.32; 95% CI [0.15, 0.73]. Two indicators were associated with favorable discharge PCPC: Avoidance of hypoxia (aRR 0.46; 95% CI [0.23, 0.93]), and Nutrition started in 72 hours (aRR 0.45; 95% CI [0.21, 0.99]). Avoiding hypoxia was also associated with favorable discharge POPC (aRR 0.47; 95% CI [0.22, 0.99]). Conclusion There is variation in Argentine ICU practice in the care of children with severe TBI. Second insults are common and hyperosmolar therapy use is uncommon. Adherence to best practice TBI care by avoiding hypoxia and providing timely nutrition were associated with significantly favorable discharge outcomes. Implementing strategies that prevent hypoxia and facilitate early nutrition in the ICUs are urgently needed to improve pediatric TBI outcomes.
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Prottengeier J, Jess N, Harig F, Gall C, Schmidt J, Birkholz T. Can we rely on out-of-hospital blood samples? A prospective interventional study on the pre-analytical stability of blood samples under prehospital emergency medicine conditions. Scand J Trauma Resusc Emerg Med 2017; 25:24. [PMID: 28259184 PMCID: PMC5336613 DOI: 10.1186/s13049-017-0371-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 02/27/2017] [Indexed: 11/18/2022] Open
Abstract
Background Prehospital intravenous access provides the opportunity to sample blood from an emergency patient at the earliest possible moment in the course of acute illness and in a state prior to therapeutic interventions. Our study investigates the pre-analytical stability of biomarkers in prehospital emergency medicine and will answer the question whether an approach of blood sampling out in the field will deliver valid laboratory results. Methods We prepared pairs of blood samples from healthy volunteers and volunteering patients post cardio-thoracic surgery. While one sample set was analysed immediately, the other one was subjected to a worse-than-reality treatment of 60 min time-lapse and standardized mechanical forces outside of the hospital through actual ambulance transport. We investigated 21 parameters comprising blood cells, coagulation tests, electrolytes, markers of haemolysis and markers of cardiac ischemia. Bland-Altman analysis was used to investigate differences between test groups. Differences between test groups were set against the official margins of test accuracy as given by the German Requirements for Quality Assurance of Medical Laboratory Examinations. Results Agreement between immediate analysis and our prehospital treatment is high as demonstrated by Bland-Altman plotting. Mechanical stress and time delay do not produce a systematic bias but only random inaccuracy. The limits of agreement for the tested parameters are generally within clinically acceptable ranges of variation and within the official margins as set by the German Requirements for Quality Assurance of Medical Laboratory Examinations. Discussion We subjected blood samples to a standardized treatment marking a worse-than-reality scenario of prehospital time delay and transport. Biomarkers including indicators of myocardial ischemia showed high pre-analytical stability. Conclusion We conclude the validity of blood samples from a prehospital environment. Electronic supplementary material The online version of this article (doi:10.1186/s13049-017-0371-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Johannes Prottengeier
- Department of Anaesthesiology, Erlangen University Hospital, Krankenhausstrasse 12, 91054, Erlangen, Germany.
| | - Nicola Jess
- Department of Child and Adolescent Psychiatry, Psychosomatics, and Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
| | - Frank Harig
- Department of Cardiac Surgery, Erlangen University Hospital, Erlangen, Germany
| | - Christine Gall
- Department of Medical Informatics, Biometry and Epidemiology, Friedrich Alexander University, Erlangen-Nuremberg, Erlangen, Germany
| | - Joachim Schmidt
- Department of Anaesthesiology, Erlangen University Hospital, Krankenhausstrasse 12, 91054, Erlangen, Germany
| | - Torsten Birkholz
- Department of Anaesthesiology, Erlangen University Hospital, Krankenhausstrasse 12, 91054, Erlangen, Germany
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