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Bozer JJ, Gruber MD, Letson MM, Crichton KG, Rice CE, Qureshi N, Leonard JR, Sribnick EA. Long-Term Functional Outcome Following Neurosurgical Intervention for Suspected Abusive Head Trauma. Pediatr Neurol 2023; 148:101-107. [PMID: 37699270 DOI: 10.1016/j.pediatrneurol.2023.08.017] [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: 03/05/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the long-term functional and neurodevelopmental outcomes in pediatric patients who underwent neurosurgical intervention following suspected abusive head trauma (AHT). METHODS We performed a single-center retrospective review (January 1, 2007, to December 31, 2019) of patients aged less than three years who had intracranial injury suspicious for AHT and received a neurosurgical procedure. Long-term functional outcome was measured using the Pediatric Cerebral Performance Category (PCPC), Pediatric Overall Performance Category (POPC), and the Mullen Scales of Early Learning (MSEL). RESULTS Seventy-seven patients were identified; 53 survived to discharge and had at least one-year follow-up. To examine long-term functional outcome, PCPC at the last available visit was examined and found to be 1 or 2 (normal to mild disability) for 64% of patients and 3 or 4 (moderate to severe disability) for 36%. The last available MSEL composite score for neurodevelopmental assessment also demonstrated that 13% of patients scored in the "average" range, 17% in the "below average" range, and 70% in the "very low" range. There was no statistical difference in the last available PCPC or POPC score or the last available MSEL score for patients who received a craniotomy when compared with those who received an intracranial shunt. CONCLUSIONS For patients with AHT who survived to discharge, functional improvements over time were noted in both patients who received craniotomy or who simply required shunt placement. These results suggest that, for patients who survive to discharge, operative management of AHT can lead to reasonable long-term functional outcomes.
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Affiliation(s)
- Jordan J Bozer
- College of Medicine, The Ohio State University, Columbus, Ohio
| | - Maxwell D Gruber
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Megan M Letson
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Kristin G Crichton
- Department of Pediatrics, The Ohio State University Wexner Medical Center, Columbus, Ohio; Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Courtney E Rice
- Psychiatry and Behavioral Health, Nationwide Children's Hospital, Columbus, Ohio
| | | | - Jeffrey R Leonard
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Eric A Sribnick
- Department of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio; Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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2
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Misirlioglu M, Ekinci F, Yildizdas D, Horoz OO, Yilmaz HL, Incecik F, Ozsoy M, Yontem A, Bilen S, Silay S. A Retrospective Cohort Study of Traumatic Brain Injury in Children: A Single-Institution Experience and Determinants of Neurologic Outcome. J Crit Care Med (Targu Mures) 2023; 9:252-261. [PMID: 37969881 PMCID: PMC10644296 DOI: 10.2478/jccm-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/19/2023] [Indexed: 11/17/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) has become a significant cause of death and morbidity in childhood since the elucidation of infectious causes within the last century. Mortality rates in this population decreased over time due to developments in technology and effective treatment modalities. Aim of the study This retrospective cohort study aimed to describe the volume, severity and mechanism of all hospital-admitted pediatric TBI patients at a university hospital over a 5-year period. Material and Methods This was a single-center, retrospective cohort study including 90 pediatric patients with TBI admitted to a tertiary care PICU. The patients' demographic data, injury mechanisms, disease and trauma severity scores, initiation of enteral nutrition and outcome measures such as hospital stay, PICU stay, duration of mechanical ventilation, mortality, and Glasgow Outcome Scale (GOS) were also recorded. Late enteral nutrition was defined as initiation of enteral feeding after 48 hours of hospitalization. Results Of the 90 patients included in the cohort, 60% had mild TBI, 21.1% had moderate TBI and 18.9% had severe TBI. Their mean age was 69 months (3-210 months). TBI was isolated in 34 (37.8%) patients and observed as a part of multisystemic trauma in 56 (62.2%). The most commonly involved site in multisystemic injury was the thorax (33.3%). The length of hospitalization in the late enteral nutrition group was significantly higher than that in the early nutrition group, while the PICU stay was not significantly different between the two groups. The multiple logistic regression analysis found a significant relationship between GOS-3rd month and PIM3 score, the presence of diffuse axonal injury and the need for CPR in the first 24 h of hospitalization. Conclusion Although our study showed that delayed enteral nutrition did not affect neurologic outcome, it may lead to prolonged hospitalization and increased hospital costs. High PIM3 scores and diffuse axonal injury are both associated with worse neurologic outcomes.
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Affiliation(s)
- Merve Misirlioglu
- Department of Pediatric Intensive Care, Mersin University Faculty of Medicine, Mersin, Turkey
| | - Faruk Ekinci
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Dincer Yildizdas
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ozden Ozgur Horoz
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Hayri Levent Yilmaz
- Department of Pediatric Emergency, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Faruk Incecik
- Department of Pediatric Neurology, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Mazhar Ozsoy
- Department of Neurosurgery, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Ahmet Yontem
- Department of Pediatric Intensive Care, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Sevcan Bilen
- Department of Pediatric Emergency, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Sena Silay
- Department of Pediatrics, Cukurova University Faculty of Medicine, Adana, Turkey
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3
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Muthiah N, Joseph B, Varga G, Vodovotz L, Sharma N, Abel TJ. Investigation of the effectiveness of vagus nerve stimulation for pediatric drug-resistant epilepsies secondary to nonaccidental trauma. Childs Nerv Syst 2023; 39:1201-1206. [PMID: 36602582 DOI: 10.1007/s00381-022-05817-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/25/2022] [Indexed: 01/06/2023]
Abstract
PURPOSE Epilepsy following non-accidental trauma (NAT) occurs in 18% of pediatric patients. About 33% of patients with epilepsy develop drug-resistant epilepsy. For these patients, vagus nerve stimulation (VNS) is a palliative treatment option. We aimed to investigate the effectiveness of VNS among pediatric NAT-related epilepsy patients compared to those with non-NAT-related epilepsy. METHODS We performed an 11-year retrospective analysis of VNS implantations for drug-resistant epilepsy at UPMC Children's Hospital of Pittsburgh. Patients were split into two groups: NAT vs. non-NAT. The primary outcome was the attainment of ≥ 50% seizure frequency reduction at 1-year post-VNS implantation. Fisher's exact tests and Wilcoxon rank-sum tests were used to compare groups. Significance was assessed at the alpha = 0.05 level. RESULTS This analysis included data from 370 pediatric VNS patients, of whom 9 had NAT-related epilepsy. NAT patients had a significantly younger age of epilepsy onset than non-NAT patients (0.3 years vs. 3.3 years). Otherwise, there were no statistically significant baseline differences between groups, including patient sex and quantity of antiseizure medications pre-VNS. Overall, 71% of NAT patients experienced ≥ 50% seizure frequency reduction compared to 48% of non-NAT patients (p = 0.269). CONCLUSION VNS may allow a higher proportion of pediatric patients with NAT-related epilepsy to achieve ≥ 50% seizure frequency reduction compared to other epilepsy etiologies. While the results of this study were not statistically significant, the effect size was large. Our results underscore the need for larger, multi-center studies to validate the effectiveness of VNS for this patient population.
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Affiliation(s)
| | - Brigit Joseph
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gregory Varga
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lena Vodovotz
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nikhil Sharma
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Taylor J Abel
- Department of Neurological Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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4
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Caré MM. Parenchymal Insults in Abuse—A Potential Key to Diagnosis. Diagnostics (Basel) 2022; 12:diagnostics12040955. [PMID: 35454003 PMCID: PMC9029348 DOI: 10.3390/diagnostics12040955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 02/01/2023] Open
Abstract
Subdural hemorrhage is a key imaging finding in cases of abusive head trauma and one that many radiologists and radiology trainees become familiar with during their years of training. Although it may prove to be a marker of trauma in a young child or infant that presents without a history of injury, the parenchymal insults in these young patients more often lead to the debilitating and sometimes devastating outcomes observed in this young population. It is important to recognize these patterns of parenchymal injuries and how they may differ from the imaging findings in other cases of traumatic injury in young children. In addition, these parenchymal insults may serve as another significant, distinguishing feature when making the medical diagnosis of abusive head injury while still considering alternative diagnoses, including accidental injury. Therefore, as radiologists, we must strive to look beyond the potential cranial injury or subdural hemorrhage for the sometimes more subtle but significant parenchymal insults in abuse.
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Affiliation(s)
- Marguerite M. Caré
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA;
- Department of Radiology and Medical Imaging, University of Cincinnati, Cincinnati, OH 45267, USA
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5
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Lindberg DM. Abusive and Nonabusive Traumatic Brain Injury: Different Diseases, Not Just Different Intent. J Pediatr 2020; 227:15-16. [PMID: 32828884 DOI: 10.1016/j.jpeds.2020.08.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Daniel M Lindberg
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado.
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6
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Even KM, Subramanian S, Berger RP, Kochanek PM, Zuccoli G, Gaines BA, Fink EL. The Presence of Anemia in Children with Abusive Head Trauma. J Pediatr 2020; 223:148-155.e2. [PMID: 32532650 DOI: 10.1016/j.jpeds.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/03/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the incidence of anemia in patients with abusive head trauma (AHT), noninflicted traumatic brain injury (TBI), and physical abuse without AHT and the effect of anemia on outcome. STUDY DESIGN In a retrospective, single-center cohort study, we included children under the age of 3 years diagnosed with either AHT (n = 75), noninflicted TBI (n = 77), or physical abuse without AHT (n = 60) between January 1, 2014, and December 31, 2016. Neuroimaging was prospectively analyzed by pediatric neuroradiologists. Primary outcome was anemia at hospital presentation. Secondary outcomes included unfavorable outcome at hospital discharge, defined as a Glasgow Outcome Scale between 1 and 3, and intracranial hemorrhage (ICH) volume. RESULTS Patients with AHT had a higher rate of anemia on presentation (47.3%) vs noninflicted TBI (15.6%) and physical abuse without AHT (10%) (P < .001). Patients with AHT had larger ICH volumes (33.3 mL [10.1-76.4 mL] vs 1.5 mL [0.6-5.2 mL] ; P < .001) and greater ICH/total brain volume percentages than patients with noninflicted TBI (4.6% [1.4-8.2 %] vs 0.2% [0.1-0.7%]; P < .001). Anemia was associated with AHT (OR, 4.7; 95% CI, 2.2-10.2) and larger ICH/total brain volume percentage (OR, 1.1; 95% CI, 1.1-1.2) in univariate analysis. Unfavorable outcome at hospital discharge was associated with anemia (OR, 4.4; 95% CI, 1.6-12.6) in univariate analysis, but not after controlling for covariates. CONCLUSIONS Patients with AHT were more likely to present to the hospital with anemia and increased traumatic ICH volume than patients with noninflicted TBI or physical abuse without AHT. Children with anemia and AHT may be at increased risk for an unfavorable outcome.
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Affiliation(s)
- Katelyn M Even
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA.
| | - Subramanian Subramanian
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Giulio Zuccoli
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Barbara A Gaines
- Department of Surgery, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA; Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
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7
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Kochanek PM, Tasker RC, Carney N, Totten AM, Adelson PD, Selden NR, Davis-O'Reilly C, Hart EL, Bell MJ, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Vavilala MS, Wainwright MS. Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Neurosurgery 2020; 84:1169-1178. [PMID: 30822776 DOI: 10.1093/neuros/nyz051] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 12/28/2022] Open
Abstract
The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, 9 are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, 3 are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The complete guideline document and supplemental appendices are available electronically (https://doi.org/10.1097/PCC.0000000000001735). The online documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Department of Anesthesiology, Pe-diatrics, Bioengineering, and Clinical and Translational Science, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Tasker
- Department of Neurology, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, Massachusetts
| | - Nancy Carney
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Annette M Totten
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - P David Adelson
- Deptartment of Pediatric Neurosurgery, BARROW Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Cynthia Davis-O'Reilly
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Erica L Hart
- Pacific Northwest Evidence-based Practice Center, Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon
| | - Michael J Bell
- Department Critical Care Medicine, Children's National Medical Center, Washington, District of Columbia
| | - Susan L Bratton
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Gerald A Grant
- Department of Neurosurgery, Stanford University, Stanford, California
| | - Niranjan Kissoon
- Department of Pediatrics, British Columbia's Children's Hospital, Child and Family Research Institute, University of British Columbia, Vancouver, Canada
| | - Karin E Reuter-Rice
- School of Nursing/School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University, Durham, North Carolina
| | - Monica S Vavilala
- Department of Anesthesiology & Pain Medicine, Department of Pediatrics, Harborview Injury Prevention and Research Center (HIPRC), University of Washington, Seattle, Washington
| | - Mark S Wainwright
- Division of Pediatric Neurology, University of Washington, Seattle Children's Hospital, Seattle, Washington
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8
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Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. J Neurosurg Pediatr 2019; 24:481-488. [PMID: 31675688 DOI: 10.3171/2019.7.peds18394] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/29/2019] [Indexed: 11/06/2022]
Abstract
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
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Affiliation(s)
- Ann-Christine Duhaime
- 1Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Cindy W Christian
- 2Department of Pediatrics, Children's Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Bonow RH, Oron AP, Hanak BW, Browd SR, Chesnut RM, Ellenbogen RG, Vavilala MS, Rivara FP. Post-Traumatic Hydrocephalus in Children: A Retrospective Study in 42 Pediatric Hospitals Using the Pediatric Health Information System. Neurosurgery 2019; 83:732-739. [PMID: 29029289 DOI: 10.1093/neuros/nyx470] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 08/30/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Post-traumatic hydrocephalus (PTH) is a potentially treatable cause of poor recovery from traumatic brain injury (TBI) that remains poorly understood, particularly among children. OBJECTIVE To better understand the risk factors for pediatric PTH using a large, multi-institutional database. METHODS We conducted a retrospective cohort study using administrative data from 42 pediatric hospitals participating in the Pediatric Health Information System. All patients ≤21 yr surviving a hospitalization with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for TBI were identified. The primary outcome was PTH, defined by an ICD-9-CM procedure code for surgical management of hydrocephalus within 6 mo. Data were analyzed using multivariable logistic regression. RESULTS We identified 91 583 patients ≤21 yr with TBI, 846 of whom developed PTH. Odds of PTH were significantly higher in children <1 yr compared to older age groups. A total of 48.7% of PTH cases were victims of abuse (adjusted odds ratio [aOR] 2.62, 95% confidence interval [CI] 2.16-3.18). PTH was more common after craniotomy (aOR 1.60, 95% CI 1.30-1.97). Craniectomy without early cranioplasty was associated with markedly increased odds of PTH (aOR 3.67, 95% CI 2.66-5.07), an effect not seen in those undergoing cranioplasty within 30 d (aOR 1.19, 95% CI 0.75-1.89). CONCLUSION PTH was seen in 0.9% of children who sustained a TBI and was more common in those <1 yr. Severe injury, abuse, and craniectomy with delayed cranioplasty were associated with greatly increased likelihood of PTH. Early cranioplasty in children who require craniectomy may reduce the risk for PTH.
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Affiliation(s)
- Robert H Bonow
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Assaf P Oron
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Brian W Hanak
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Samuel R Browd
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Randall M Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington.,Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington
| | - Richard G Ellenbogen
- Department of Neurological Surgery, University of Washington, Seattle, Washington
| | - Monica S Vavilala
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Frederick P Rivara
- Harborview Injury Prevention Research Center, Harborview Medical Center, Seattle, Washington.,Department of Pediatrics, University of Washington, Seattle, Washington
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10
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Manfiotto M, Beccaria K, Rolland A, Paternoster G, Plas B, Boetto S, Vinchon M, Mottolese C, Beuriat PA, Szathmari A, Di Rocco F, Scavarda D, Seigneuret E, Wrobleski I, Klein O, Joud A, Gimbert E, Jecko V, Vignes JR, Roujeau T, Dupont A, Zerah M, Lonjon M. Decompressive Craniectomy in Children with Severe Traumatic Brain Injury: A Multicenter Retrospective Study and Literature Review. World Neurosurg 2019; 129:e56-e62. [PMID: 31054345 DOI: 10.1016/j.wneu.2019.04.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/23/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
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11
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Fraser BD, Lingo PR, Khan NR, Vaughn BN, Klimo P. Pediatric Abusive Head Trauma: Return to Hospital System in the First Year Post Injury. Neurosurgery 2019; 85:E66-E74. [PMID: 30476266 DOI: 10.1093/neuros/nyy456] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 09/03/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Abusive head trauma (AHT) may result in costly, long-term sequelae. OBJECTIVE To describe the burden of AHT on the hospital system within the first year of injury. METHODS Single institution retrospective evaluation of AHT cases from January 2009 to August 2016. Demographic, clinical (including injury severity graded I-III), and charge data associated with both initial and return hospital visits within 1 yr of injury were extracted. RESULTS A total of 278 cases of AHT were identified: 60% male, 76% infant, and 54% African-American. Of these 278 cases, 162 (60%) returned to the hospital within the first year, resulting in 676 total visits (an average of 4.2 returns/patient). Grade I injuries were less likely to return than more serious injuries (II and III). The majority were outpatient services (n = 430, 64%); of the inpatient readmissions, neurosurgery was the most likely service to be involved (44%). Neurosurgical procedures accounted for the majority of surgeries performed during both initial admission and readmission (85% and 68%, respectively). Increasing injury severity positively correlated with charges for both the initial admission and returns (P < .001 for both). Total calculated charges, including initial admission and returns, were over $25 million USD. CONCLUSION AHT has a high potential for return to the hospital system within the first year. Inpatient charges dominate and account for the vast majority of hospital returns and overall charges. A more severe initial injury correlates with increased charges on initial admission and on subsequent hospital return.
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Affiliation(s)
- Brittany D Fraser
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - P Ryan Lingo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Nickalus R Khan
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.,Le Bonheur Children's Hospital, Memphis, Tennessee.,Semmes Murphey, Memphis, Tennessee
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12
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines, Executive Summary. Pediatr Crit Care Med 2019; 20:280-289. [PMID: 30830016 DOI: 10.1097/pcc.0000000000001736] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this work is to identify and synthesize research produced since the second edition of these Guidelines was published and incorporate new results into revised evidence-based recommendations for the treatment of severe traumatic brain injury in pediatric patients. METHODS AND MAIN RESULTS This document provides an overview of our process, lists the new research added, and includes the revised recommendations. Recommendations are only provided when there is supporting evidence. This update includes 22 recommendations, nine are new or revised from previous editions. New recommendations on neuroimaging, hyperosmolar therapy, analgesics and sedatives, seizure prophylaxis, temperature control/hypothermia, and nutrition are provided. None are level I, three are level II, and 19 are level III. The Clinical Investigators responsible for these Guidelines also created a companion algorithm that supplements the recommendations with expert consensus where evidence is not available and organizes possible interventions into first and second tier utilization. The purpose of publishing the algorithm as a separate document is to provide guidance for clinicians while maintaining a clear distinction between what is evidence based and what is consensus based. This approach allows, and is intended to encourage, continued creativity in treatment and research where evidence is lacking. Additionally, it allows for the use of the evidence-based recommendations as the foundation for other pathways, protocols, or algorithms specific to different organizations or environments. The complete guideline document and supplemental appendices are available electronically from this journal. These documents contain summaries and evaluations of all the studies considered, including those from prior editions, and more detailed information on our methodology. CONCLUSIONS New level II and level III evidence-based recommendations and an algorithm provide additional guidance for the development of local protocols to treat pediatric patients with severe traumatic brain injury. Our intention is to identify and institute a sustainable process to update these Guidelines as new evidence becomes available.
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13
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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14
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Araki T. Pediatric Neurocritical Care. Neurocrit Care 2019. [DOI: 10.1007/978-981-13-7272-8_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lee JK, Brady KM, Deutsch N. The Anesthesiologist's Role in Treating Abusive Head Trauma. Anesth Analg 2017; 122:1971-82. [PMID: 27195639 DOI: 10.1213/ane.0000000000001298] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Abusive head trauma (AHT) is the most common cause of severe traumatic brain injury (TBI) in infants and the leading cause of child abuse-related deaths. For reasons that remain unclear, mortality rates after moderate AHT rival those of severe nonintentional TBI. The vulnerability of the developing brain to injury may be partially responsible for the poor outcomes observed after AHT. AHT is mechanistically more complex than nonintentional TBI. The acute-on-chronic nature of the trauma along with synergistic injury mechanisms that include rapid rotation of the brain, diffuse axonal injury, blunt force trauma, and hypoxia-ischemia make AHT challenging to treat. The anesthesiologist must understand the complex injury mechanisms inherent to AHT, as well as the pediatric TBI treatment guidelines, to decrease the risk of persistent neurologic disability and death. In this review, we discuss the epidemiology of AHT, differences between AHT and nonintentional TBI, the severe pediatric TBI treatment guidelines in the context of AHT, anesthetic considerations, and ethical and legal reporting requirements.
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Affiliation(s)
- Jennifer K Lee
- From the *Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesiology, Johns Hopkins University, Baltimore, Maryland; †Department of Pediatrics, Anesthesia, and Critical Care, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and ‡Departments of Anesthesiology and Pediatrics, Children's National Health System, Washington DC
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Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo) 2017; 57:82-93. [PMID: 28111406 PMCID: PMC5341344 DOI: 10.2176/nmc.ra.2016-0191] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.
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Affiliation(s)
- Takashi Araki
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Abstract
Traumatic brain injury (TBI) refers to a spectrum of brain injury that can result in significant morbidity and mortality in pediatric patients. Pediatric head trauma is distinct from adult TBI. The purpose of this review article is to discuss pediatric TBI and current treatment modalities available.
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Affiliation(s)
- Nicole Sharp
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Kelly Tieves
- Department of Pediatrics, Critical Care Medicine, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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Vadivelu S, Esernio-Jenssen D, Rekate HL, Narayan RK, Mittler MA, Schneider SJ. Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes. World Neurosurg 2015; 84:1340-6. [PMID: 26118721 DOI: 10.1016/j.wneu.2015.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation. OBJECTIVE Extent of delay in seeking medical attention may be related to patient outcome. METHODS A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case. RESULTS All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay. CONCLUSION Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.
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Affiliation(s)
- Sudhakar Vadivelu
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA.
| | - Debra Esernio-Jenssen
- Department of Pediatrics, University of Florida School of Medicine at Shands Children's Hospital, Gainesville, Florida, USA
| | - Harold L Rekate
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Raj K Narayan
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Mark A Mittler
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Steven J Schneider
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
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Nishimoto H. Recent progress and future issues in the management of abusive head trauma. Neurol Med Chir (Tokyo) 2015; 55:296-304. [PMID: 25797781 PMCID: PMC4628176 DOI: 10.2176/nmc.ra.2014-0349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Head trauma is the leading cause of death in child abuse cases and one of the important issues in the care of abused children. Since the Child Abuse Prevention Law was enforced in 2000 in Japan, various measures have been taken to prevent child abuse over the following decade. Accordingly, medical research on abusive head trauma (AHT) has advanced, leading to significant progress in the medical diagnosis of AHT. This progress has been brought about by (1) the widespread establishment of child protection teams (CPTs) at core hospitals, (2) the progress in neuroradiological imaging and ophthalmoscopic technologies, and (3) the introduction of postmortem imaging. However, the pathological condition of patients with AHT, particularly that of the diffuse brain swelling type, still remains poorly understood. As a result, no clear treatment strategies for AHT have been developed and no treatment outcomes have been improved to date. The development of new treatment strategies for AHT and the construction of a comprehensive database that supports clinical studies are required in the future.
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Affiliation(s)
- Hiroshi Nishimoto
- Department of Neurosurgery, Saitama Children's Medical Center, Iwatsuki, 2. Department of Neurosurgery, Kasukabe Municipital Hospital, Kasukabe, Saitama, Japan
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Abstract
Head injury in children is one of the most common causes of death and disability in the US and, increasingly, worldwide. This chapter reviews the causes, patterns, pathophysiology, and treatment of head injury in children across the age spectrum, and compares pediatric head injury to that in adults. Classification of head injury in children can be organized according to severity, pathoanatomic type, or mechanism. Response to injury and repair mechanisms appear to vary at different ages, and these may influence optimal treatment; however, much work is still needed before investigation leads to clearly effective clinical interventions. This is true both for the more severe injuries as well as those at the milder end of the injury spectrum, the latter of which have received increasing attention. In this chapter, neuroassessment tools for each age, newer imaging modalities including magnetic resonance imaging (MRI), and specific pediatric management issues, including intracranial pressure (ICP) monitoring and seizure prophylaxis, are reviewed. Finally, specific head injury patterns and functional outcomes relevant to pediatric patients are discussed. While head injury is common, the number of head-injured children is significantly smaller than the corresponding adult head-injured population. When divided further by specific ages, injury types, and other sources of heterogeneity, properly powered clinical research is likely to require large data sets that will allow for stratification across variables, including age. While much has been learned in the past several decades, further study will be required to determine the best management practices for optimizing recovery in individual pediatric patients. This approach is likely to depend on collaborative international head injury databases that will allow researchers to better understand the nuanced evolution of different types of head injury in patients at each age, and the pathophysiologic, treatment-related, and genetic factors that influence recovery.
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Paul AR, Adamo MA. Non-accidental trauma in pediatric patients: a review of epidemiology, pathophysiology, diagnosis and treatment. Transl Pediatr 2014; 3:195-207. [PMID: 26835337 PMCID: PMC4729847 DOI: 10.3978/j.issn.2224-4336.2014.06.01] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Non-accidental trauma (NAT) is a leading cause of childhood traumatic injury and death in the United States. It is estimated that 1,400 children died from maltreatment in the United States in 2002 and abusive head trauma (AHT) accounted for 80% of these deaths. This review examines the epidemiology and risk factors for NAT as well as the general presentation and required medical work up of abused children. In addition, potential algorithms for recognizing cases of abuse are reviewed as well as outcomes in children with NAT and potential neurosurgical interventions which may be required. Finally, the evidence for seizure prophylaxis in this population is addressed.
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Affiliation(s)
- Alexandra R Paul
- Department of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, Mail Code 10, Albany, NY 12208, USA
| | - Matthew A Adamo
- Department of Neurosurgery, Albany Medical Center, 47 New Scotland Avenue, Mail Code 10, Albany, NY 12208, USA
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Stewart CL, Holscher CM, Moore EE, Bronsert M, Moulton SL, Partrick DA, Bensard DD. Base deficit correlates with mortality in pediatric abusive head trauma. J Pediatr Surg 2013; 48:2106-11. [PMID: 24094965 DOI: 10.1016/j.jpedsurg.2013.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND/PURPOSE Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome. METHODS We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05. RESULTS Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05). CONCLUSIONS BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT.
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Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma. J Trauma Acute Care Surg 2013; 75:157-60. [PMID: 23940862 DOI: 10.1097/ta.0b013e3182984acb] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to determine if the morbidity and mortality associated with traumatic brain injury (TBI) are worse in children who experienced nonaccidental trauma (NAT) compared with TBI from other traumatic mechanisms. METHODS We identified all pediatric patients admitted with the diagnosis of TBI between 2001 and 2010 in our institutional trauma registry with an Abbreviated Injury Scale (AIS) score greater than 1. Patients were divided into groups based on a nonaccidental (NAT) or accidental mechanism of injury. Need for gastrostomy tube insertion was used as a marker of more severe neurologic morbidity in survivors of TBI. Group comparisons were made using Fisher's exact tests. RESULTS A total of 2,782 patients with TBI were included; 315 (11.3%) patients had TBI secondary to NAT. Overall mortality and AIS-specific mortality were higher in patients with TBI secondary to NAT. In comparison with patients with TBI secondary to accidental mechanisms, patients with TBI secondary to NAT were younger (mean, 1 year vs. 8 years), had longer intensive care unit stays (mean, 3 days vs. 1 day), and required gastrostomy tubes more often (6% vs. 1%, p < 0.0001). Even among the subgroup of patients with severe TBI, (AIS score 4 and 5), patients with NAT required gastrostomy tubes more often (5% vs. 2%, p = 0.014). CONCLUSION Patients with TBI from NAT have increased morbidity and mortality compared with patients with TBI from accidental mechanisms; these differences are present at all levels of severity of injury. Patients with TBI from NAT represent a vulnerable group of pediatric trauma patients who are at increased risk for death and worse outcome and who will require greater short- and long-term medical resources.
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