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Chevignard M, Câmara-Costa H, Dellatolas G. Predicting and improving outcome in severe pediatric traumatic brain injury. Expert Rev Neurother 2024; 24:963-983. [PMID: 39140714 DOI: 10.1080/14737175.2024.2389921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION Severe pediatric traumatic brain injury (spTBI), including abusive head trauma (AHT) in young children, is a major public health problem. Long-term consequences of spTBI include a large variety of physical, neurological, biological, cognitive, behavioral and social deficits and impairments. AREAS COVERED The present narrative review summarizes studies and reviews published from January 2019 to February 2024 on spTBI. Significant papers published before 2019 were also included. The article gives coverage to the causes of spTBI, its epidemiology and fatality rates; disparities, inequalities, and socioeconomic factors; critical care; outcomes; and interventions. EXPERT OPINION There are disparities between countries and according to socio-economic factors regarding causes, treatments and outcomes of spTBI. AHT has an overall poor outcome. Adherence to critical care guidelines is imperfect and the evidence-base of guidelines needs further investigations. Neuroimaging and biomarker predictors of outcomes is a rapidly evolving domain. Long-term cognitive, behavioral and psychosocial difficulties are the most prevalent and disabling. Their investigation should make a clear distinction between objective (clinical examination, cognitive tests, facts) and subjective measures (estimations using patient- and proxy-reported questionnaires), considering possible common source bias in reported difficulties. Family/caregiver-focused interventions, ecological approaches, and use of technology in delivery of interventions are recommended to improve long-term difficulties after spTBI.
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Affiliation(s)
- Mathilde Chevignard
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Hugo Câmara-Costa
- Rehabilitation Department for Children with Acquired Neurological Injury, Saint Maurice Hospitals, Saint Maurice, France
- Sorbonne Université, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale (LIB), Paris, France
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
| | - Georges Dellatolas
- Sorbonne Université, GRC 24 Handicap Moteur Cognitif et Réadaptation (HaMCRe), AP-HP, Paris, France
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Bergus KC, Patterson KN, Asti L, Bricker J, Beyene TJ, Schulz LN, Schwartz DM, Thakkar RK, Sribnick EA. Association of initial assessment variables and mortality in severe pediatric traumatic brain injury. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000718. [PMID: 38818384 PMCID: PMC11138288 DOI: 10.1136/wjps-2023-000718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 05/07/2024] [Indexed: 06/01/2024] Open
Abstract
Background Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality. Methods Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression. Results Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%. Conclusions Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.
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Affiliation(s)
- Katherine C Bergus
- Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Kelli N Patterson
- Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lindsey Asti
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Josh Bricker
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Tariku J Beyene
- Center for Surgical Outcomes Research, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lauren N Schulz
- Neurologic Surgery, The Ohio State University, Columbus, Ohio, USA
- Neurologic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Dana M Schwartz
- Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rajan K Thakkar
- Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Eric A Sribnick
- Neurologic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
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Sullivan TM, Sippel GJ, Matison EA, Gestrich-Thompson WV, DeWitt PE, Carlisle MA, Oluigbo D, Oluigbo C, Bennett TD, Burd RS. Development and validation of a Bayesian network predicting neurosurgical intervention after injury in children and adolescents. J Trauma Acute Care Surg 2023; 94:839-846. [PMID: 36917100 PMCID: PMC10205657 DOI: 10.1097/ta.0000000000003935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023]
Abstract
BACKGROUND Timely surgical decompression improves functional outcomes and survival among children with traumatic brain injury and increased intracranial pressure. Previous scoring systems for identifying the need for surgical decompression after traumatic brain injury in children and adults have had several barriers to use. These barriers include the inability to generate a score with missing data, a requirement for radiographic imaging that may not be immediately available, and limited accuracy. To address these limitations, we developed a Bayesian network to predict the probability of neurosurgical intervention among injured children and adolescents (aged 1-18 years) using physical examination findings and injury characteristics observable at hospital arrival. METHODS We obtained patient, injury, transportation, resuscitation, and procedure characteristics from the 2017 to 2019 Trauma Quality Improvement Project database. We trained and validated a Bayesian network to predict the probability of a neurosurgical intervention, defined as undergoing a craniotomy, craniectomy, or intracranial pressure monitor placement. We evaluated model performance using the area under the receiver operating characteristic and calibration curves. We evaluated the percentage of contribution of each input for predicting neurosurgical intervention using relative mutual information (RMI). RESULTS The final model included four predictor variables, including the Glasgow Coma Scale score (RMI, 31.9%), pupillary response (RMI, 11.6%), mechanism of injury (RMI, 5.8%), and presence of prehospital cardiopulmonary resuscitation (RMI, 0.8%). The model achieved an area under the receiver operating characteristic curve of 0.90 (95% confidence interval [CI], 0.89-0.91) and had a calibration slope of 0.77 (95% CI, 0.29-1.26) with a y intercept of 0.05 (95% CI, -0.14 to 0.25). CONCLUSION We developed a Bayesian network that predicts neurosurgical intervention for all injured children using four factors immediately available on arrival. Compared with a binary threshold model, this probabilistic model may allow clinicians to stratify management strategies based on risk. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Travis M. Sullivan
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Genevieve J. Sippel
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | - Elizabeth A. Matison
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
| | | | - Peter E. DeWitt
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Chima Oluigbo
- Department of Neurological Surgery, Children’s National Hospital, Washington, DC
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics, University of Colorado School of Medicine, Aurora, CO
- Children’s Hospital of Colorado, Aurora, CO
| | - Randall S. Burd
- Division of Trauma and Burn Surgery, Children’s National Hospital, Washington, DC
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Patterson KN, Nordin A, Beyene TJ, Onwuka A, Bergus K, Horvath KZ, Sribnick EA, Thakkar RK. Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center. J Surg Res 2022; 275:308-317. [DOI: 10.1016/j.jss.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/08/2021] [Accepted: 02/10/2022] [Indexed: 11/16/2022]
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