Keywords Glasgow outcome score - intensive care unit - pediatric - traumatic brain injury
Introduction
Traumatic brain injury (TBI) is defined as an alteration in brain function, or other
evidence of brain pathology, caused by an external force.[1 ] It is a major health concern worldwide across socioeconomic and demographic barriers.
It is multifarious in etiology and mechanism with varying outcomes. Head injury in
children can cause long-term sequelae, ranging from physical disability to hampering
emotional and mental growth and cognitive impairment. In developing nations having
medical and financial resources limitations, it causes a big burden on the individual
as well as nation. In 2013, a total of approximately 2.8 million TBI-related emergency
department (ED) visits, hospitalizations, and deaths (TBI-EDHDs) occurred in the United
States. The highest rates of TBI-EDHDs were among the oldest or youngest age groups.
The most common principal mechanisms of injury for TBI-EDHDs were falls, being struck
by or against an object, and road traffic accidents (RTA). Approximately half of all
fall-related TBI-EDHDs occurred among those aged 0 to 4 years and ≥ 75 years.[2 ] Pediatric TBI has distinctive pathophysiology and characteristics that differ from
adults. These can be attributed to age-related anatomical and physiological differences
and distinct patterns of injuries seen in children.
The aim of the present study was to collect demographic, admission, neurocritical
care and intraoperative variables and its impact on the care of the children with
head injury. Prognostic factors associated with poor functional outcome and mortality
in a cohort of pediatric TBI patients were identified.
Methods
After approval of the Institute Ethics Committee, this retrospective study was conducted
in the neurotrauma intensive care unit (NICU) at Jai Prakash Narayan Apex Trauma Center
(JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India. Medical
records over a period of 1 year (May 2016–April 2017) were reviewed and included children
with head injury under 12 years of age admitted to the NICU. The following data was
collected: age, sex, height, weight, time from injury to admission in NICU, mechanism
of injury, NICU admission vitals including pulse rate, respiratory rate, blood pressure
and oxygen saturation, postresuscitation Glasgow coma scale (GCS), associated injuries,
radiological findings, cranial/extracranial surgery, amount of intraoperative blood
loss and blood transfusion, duration of anesthesia, ICU stay and hospital stay, and
Glasgow outcome scale (GOS) at discharge. GOS ≤ 3 was taken as a poor outcome.
Compiled data was collated and analyzed using Stata Statistical Software: Release
13 College Station, TX: StataCorp LP. Descriptive values were expressed as frequencies
for dichotomous variables and as mean ± standard deviation (SD) or median (minimum-maximum
value) for continuous variables. Univariate analysis was done using Chi-square test
or Fisher exact test to identify variables associated with mortality and poor outcome.
Then, multivariate logistic regression was utilized to identify factors associated
with mortality and poor outcome independently, and odds ratio was also calculated.
p value less than 0.05 was considered significant.
Results
A total of 105 children with head injury were admitted in the NICU during the period
from May 2016 to April 2017. Basic demographic data are given in [Table 1 ]. Mechanisms of injury are described in [Table 2 ], with the most common mechanism being fall in 78% and RTA in 15.4% of the patients,
with pedestrians being involved in 8.6% cases. Fifty-four patients (51.4%) presented
with a severe head injury (GCS ≤ 8) while 31 (29.5%) and 20 (19.1%) had a mild and
moderate head injury (GCS 13–15 and GCS 9–12), respectively, with a median postresuscitation
GCS of 7 (range 3–15) ([Fig. 1 ]).
Table 1
Basic demographic data
Variable
Mean (SD)/median (range)/ratio
Abbreviation: SD, standard deviation.
Age
4 years (14 days to 12 years)
Male to female ratio
1.33
Age group 0–4 years (male/female ratio)
0.94
Age group 4–12 years (male/female ratio)
2.4
Height (cm)
98.6 (22.2)
Weight (kg)
15.5 (7.2)
Time from injury to admission in ICU
3.75 hours (0.5 to 55 hours)
Table 2
Mechanism of injury
Mechanism of injury
0–4 years
4–12 years
Frequency
%
Abbreviation: RTA, road traffic accident.
a Others—assault blunt instrument, fall of object on head, other violence, and unknown
cause.
RTA pedestrian
3
6
9
8.6
RTA cyclist
1
0
1
1.0
RTA motorcyclist
2
1
3
2.9
RTA other vehicle occupant
0
3
3
2.9
Fall
54
28
82
78
Othersa
2
5
7
6.6
Total
62 (59%)
43 (41%)
105
100
Fig. 1 Postresuscitation Glasgow coma scale (GCS) in the patients. 1: Mild head injury.
2: Moderate head injury. 3: Severe head injury.
Radiological diagnosis based on CT scan of the head was undertaken in all the patients
and is described in [Table 3 ]. The most common finding was skull fractures in 59% of the patients, with contusions
being present in 36.2% and subdural hematoma (SDH) in 30.4% of the patients. Only
five children had associated extracranial injuries, in which one patient had an odontoid
process fracture with no canal compromise, second had a hemopneumothorax, another
one had a grade I splenic injury, while two patients had fractures of the shaft of
the femur.
Table 3
Radiological findings on CT scan
CT scan finding
Frequency
%
No abnormality
5
4.8
Skull fracture
62
59.0
Contusion
38
36.2
Subarachnoid / Intraventricular hemorrhage
10
9.5
Intracerebral hemorrhage
10
9.5
Extradural hematoma
20
19.0
Subdural hematoma
32
30.4
Diffuse axonal injury
2
1.9
Pneumocephalus
7
6.7
Hypoxic damage/infarct
8
7.6
Midline shift/mass effect
15
14.3
Diffuse edema
7
6.7
Patient’s vital parameters (mean ± SD) on presentation in the NICU were found to be
a respiratory rate of 20 ± 3 breaths per minute, pulse rate of 114 ± 29 beats per
minute, systolic blood pressure of 111 ± 18 mm Hg, diastolic blood pressure of 71
± 13 mm Hg, and oxygen saturation of 97 ± 3%. In all the patients, crystalloids were
used as the fluid for resuscitation. Of the 10 patients requiring vasopressors, noradrenaline
was used in six, and dopamine was used in four patients. Mechanical ventilation was
instituted in 65.7% of the patients in the NICU with a median duration of respiratory
support for 5.5 (Interquartile range [IQR] 1, 50) days, and 23 of those patients were
tracheostomized during the hospital stay. None of the patients developed ventilator-associated
pneumonia. Maintenance of sedation and analgesia was achieved using a combination
of fentanyl and midazolam infusion in the majority of the patients (91.4%). However,
dexmedetomidine was also used as a sedative/analgesic therapy in nine patients.
Various neurosurgical interventions were undertaken in the management of these patients.
Forty-five patients (42.9%) required craniectomy/craniotomy ± evacuation of clot and
four patients underwent surgery for elevation of depressed fracture. Intracranial
pressure (ICP) monitoring in the NICU was undertaken in 37 patients (35.2%) and an
external ventricular drain was inserted in three patients (2.9%) for both measurement
and management of raised ICP. Protocol based on pediatric traumatic head injury guidelines
was undertaken in the NICU management of these patients. In patients undergoing surgery,
the median duration of anesthesia was 205 (IQR 65, 375) minutes, and median blood
loss during the surgery was 16.7 mL/kg body weight with 41% requiring intraoperative
blood transfusions. General anesthesia with sevoflurane and air was the preferred
choice of anesthesia, and total intravenous anesthesia was used in only five patients.
The patients who had extracranial injuries had undergone intervention/surgeries, which
included hip Spica application in one and an external fixator application and fasciotomy
in another for fracture shaft of the femur, intercostal drain insertion for hemopneumothorax,
and C1-C2 cervical spine fixation was done in patient with fracture of the odontoid
process. A 6-month-old child was diagnosed with spinal cord injury without radiological
abnormality (SCIWORA) 3 days after the history of fall from bed. The CT scan of head
and cervical spine showed no abnormality, but there were no upper and lower limb movements
in the child. MRI was done which showed cord edema at C4 level.
Median duration of ICU and hospital stay was 5 (IQR 1, 47) and 8 (IQR 1, 123) days,
respectively. Fifteen patients died prior to discharge in NICU (14.3%). Patients who
expired had a median age of 2 years, with 60% of them being females, and their postresuscitation
median GCS was 5 with 93.3% having severe head injury. Skull fractures followed by
SDH were the two most common radiological findings present in 60% and 53.3% of these
patients, respectively. Median hospital stay was 5 (IQR 1, 22) days.
Variables associated with mortality on univariate analysis are shown in [Table 4 ] and variables associated with poor outcome on univariate analysis are shown in [Table 5 ]. Multivariate analysis identified postresuscitation GCS ≤ 8 on admission as independent
predictors of mortality with a p value < 0.05 ([Table 6 ]). GOS at discharge ≤ 3 representing poor outcome was present in 35 patients (33.3%)
and a favorable outcome was present in 55 patients (52.4%). Multivariate analysis
identified postresuscitation GCS ≤ 8 on admission and NICU stay of > 7 days as independent
factors predicting poor outcome with a p value < 0.05 ([Table 6 ]).
Table 4
Characteristics and univariate analysis of variables associated with mortality
Variable
Expired
n = 15 (14.3%)
Alive
n = 90 (85.7%)
p -Value
Abbreviations: EDH, extradural hematoma; GCS, Glasgow coma scale; ICH, intracerebral
hemorrhage; ICP, intracranial pressure; IVH, intraventricular hemorrhage; NICU, neurotrauma
intensive care unit; SAH, subarachnoid hemorrhage; SDH, subdural hematoma.
a Date available for 98 patients.
Age
< 4 years
13 (12.4%)
49 (46.6%)
0.02
4–12 years
2 (2.0%)
41 (39.0%)
Sex
Male
6 (5.7%)
54 (51.4%)
0.15
Female
9 (8.6%)
36 (34.3%)
Time to admission a (n = 98)
0–4 hours
10 (9.5%)
44 (42.0%)
0.6
4–12 hours
4 (3.8%)
29 (27.6%)
> 12 hours
1 (0.9%)
10 (9.5%)
Postresuscitation GCS on admission
< 8
14 (13.3%)
40 (38.0%)
< 0.001
9–15
1 (0.9%)
50 (47.6%)
CT scan findings
Skull fracture
9 (8.6%)
53 (50.5%)
0.93
Contusion
5 (4.7%)
33 (31.4%)
0.80
SAH/IVH
2 (2.0%)
8 (7.6%)
0.63
ICH
1 (0.9%)
9 (8.6%)
1
EDH
2 (2.0%)
18 (17.1%)
0.73
SDH
8 (7.6%)
24 (23.0%)
0.04
Pneumocephalus
1 (0.9%)
6 (5.7%)
1
Hypoxic damage/infarct
2(2.0%)
6 (5.7%)
0.32
Diffuse edema
4 (3.8%)
3 (2.8%)
0.008
Midline shift/mass effect
3 (2.8%)
12 (11.4%)
0.44
ICP monitoring
5 (4.7%)
32 (30.4%)
0.86
Surgery:
a. Craniotomy/craniectomy +/- hematoma evacuation
b. Elevation of depressed fracture
7 (6.6%)
1 (1.0%)
38 (36.1%)
03 (2.8%)
0.74
Duration of anesthesia
< 180 minute
6 (5.7%)
27 (25.7%)
1.0
> 180 minute
2 (2.0%)
14 (13.3%)
Blood loss
< 15ml/kg
3 (2.8%)
21 (20.0%)
0.14
15–30 ml/kg
3 (2.8%)
18 (17.1%)
> 30 mL/kg
2 (2.0%)
2 (2.0%)
Blood transfusion
Yes
8 (7.6%)
35 (33.3%)
0.29
No
7 (6.6%)
55 (52.3%)
Duration of NICU stay
< 7 days
12 (11.4%)
52 (49.5%)
0.15
> 7 days
3 (2.8%)
38 (36.1%)
Table 5
Characteristics and univariate analysis of variables associated with poor outcome
(GOS ≤ 3)
Variable
GOS ≤ 3
n = 35 (33.3%)
GOS 4–5
n = 55 (52.4%)
p -Value
Abbreviations: EDH, extradural hematoma; GCS, Glasgow coma scale; GOS, Glasgow outcome
scale; ICH, intracerebral hemorrhage; ICP, intracranial pressure; IVH, intraventricular
hemorrhage; NICU, neurotrauma intensive care unit; RTA, road traffic accident; SAH,
subarachnoid hemorrhage; SDH, subdural hematoma.
a Date available for 84 patients.
Age
< 4 years
16 (15.2%)
33 (31.4%)
0.18
4–12 years
19 (18.1%)
22 (21.0%)
Sex
Male
19 (18.1%)
35 (33.3%)
0.38
Female
16 (15.2%)
20 (19.0%)
Mechanism of injury
Fall
22 (21.0%)
48 (45.7%)
0.02
RTA
8 (7.6%)
5 (4.8%)
Others
5 (4.8%)
2 (1.9%)
Time to admissiona
0–4 hours
4 (3.8%)
8 (7.6%)
0.86
4–12 hours
20 (19.0%)
31 (29.5%)
> 12 hours
9 (8.6%)
12 (11.4%)
Post resuscitation GCS on admission
< 8
28 (26.6%)
18 (17.1%)
<0.001
9–15
7 (6.7%)
37 (35.2%)
CT scan findings
Skull fracture
20 (19.0%)
33 (31.4%)
0.79
Contusion
15 (14.3%)
18 (17.1%)
0.33
SAH/IVH
4 (3.8%)
4 (3.8%)
0.70
ICH
6 (5.7%)
3 (2.9%)
0.08
EDH
3 (2.9%)
15 (14.3%)
0.03
SDH
7 (6.7%)
17 (16.2%)
0.25
Pneumocephalus
1 (1.0%)
5 (4.8%)
0.39
Hypoxic damage/infarct
3 (3.0%)
3 (3.0%)
0.67
Diffuse edema
2 (2.0%)
1(0.9%)
0.55
Midline shift/ mass effect
7 (7.0%)
5(4.7%)
0.14
ICP monitoring
19 (18.0%)
13 (12.4%)
0.003
Surgery:
a. Craniotomy/craniectomy +/- hematoma evacuation
b. Elevation of depressed fracture
15 (14.0%)
0 (0.0%)
23 (21.9%)
03 (2.9%)
0.92
Duration of anesthesia
< 180 minute
3 (3.0%)
11 (10.5%)
> 180 minute
12(11.0%)
15 (14.3%)
0.18
Blood transfusion
Yes
13 (12.0%)
22 (21.0%)
0.78
No
22(21.0%)
33 (31.4%)
Duration of NICU stay
< 7 days
8 (8.2%)
44 (41.9%)
< 0.001
> 7 days
27 (26.2%)
11 (10.5%)
Duration of hospital stay
< 30 days
31 (30%)
54 (51.4%)
0.07
> 30 days
4 (4%)
1 (0.9%)
Table 6
Independent and significant factors predicting mortality and poor outcome in multivariate
analysis
OR
95% CI
p -Value
Abbreviations: CI, confidence interval; GCS, Glasgow coma scale; GOS, Glasgow outcome
scale; NICU, neurotrauma intensive care unit; OR, odds ratio.
a Age < 4 years vs. 4–12 years.
b Postresuscitation GCS ≤8 vs. 9–15.
c Duration of stay NICU stay < 7 days vs. > 7 days.
Predictive factors for mortality (n = 15)
Agea
5.03
1.3 - 31.9
0.072
Postresuscitation GCSb
24.9
2.41 – 257.32
0.007
Diffuse edema on CT
6.46
0.82 – 50.72
0.076
Predictive factors for poor outcome GOS ≤ 3 (n = 35)
Post resuscitation GCSb
3.51
1.06 – 11.52
0.038
Duration of NICU stayc
8.83
2.82 – 27.58
< 0.001
Discussion
TBI is among the common causes of mortality and disability in the pediatric age group
worldwide. It is a rising major health problem across boundaries and socioeconomic
status. Mechanisms of TBI often have age-dependent association, with falls being common
in the pediatric age group.
The median age in our study was found to be 4 years, with 59% of the children with
TBI falling under 4 years of age with a female predominance. Above that age, there
was a male predominance. In the US, highest rates of TBI-EDHD were observed among
those aged ≥ 75 years, followed by 0 to 4 years, with an overall male to female to
ratio of 1.18.[2 ] However, increased number of girls injured under the age of 4 years in our study
may be related to reduced care and supervision given to female child.
Median time from injury to admission was 3.75 hours in our hospital, with seven patients
(6.7%) reaching after 24 hours from time to injury. Variable time to admission ranging
from 1 hour to 24 hours has been reported, depending upon prehospital services, transportation
system and referral system present.[3 ]
[4 ] Reduction in prehospital time is important for improving outcomes. However, we did
not find a correlation between time to admission and outcome in our study.
Fall was the most common mechanism of injury in 78.1% of the patients, followed by
pedestrians involved in RTA. Developing nations experienced lower rates of RTA-related
TBI, and injured children were more commonly pedestrians.[5 ] More than 50% of TBI in children was accounted for by falls in studies from developed
as well as developing countries.[2 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
Improved parental supervision, and road and home safety measures can decrease the
incidence of this trauma.
Severe TBI accounted for 51.4% of the children in our study. However, majority of
the studies show more than 80% children have mild TBI in severity, except few studies
which show > 40% patients presented with severe TBI.[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ] We included only the patients admitted in the ICU, excluding those who might have
been shifted to the wards or discharged from ED, which could be the reason for higher
number of patients with severe TBI in this study.
There were multiple intracranial pathologies per child. The most common radiological
finding was skull fracture in 59% of the patients, followed by contusions and SDH
as 36.2% and 30.4%, respectively. Only 4.8% had a normal scan in our study out of
the 31 children with mild TBI as compared with (58%– 92%) in studies that included
mostly mild TBI.[17 ]
[18 ]
[19 ] Studies have reported that patients with abnormal CT scan most commonly had skull
fractures (19%–45%) and contusions (15% to 61%).[3 ]
[8 ]
[15 ]
[17 ]
[19 ] Skull bones of the children are thin and pliable, making them prone to be fractured
by less blunt forces as compared with adults.
Majority of pediatric TBI are managed nonoperatively as they are commonly mild TBI.
Our study had a high-operative rate due to the increased number of patients with severe
TBI, which required NICU admission and intervention. Similarly, reports which had
higher severe head injury had an increased rate of surgeries (21%–63%).[15 ]
[20 ] Among interventions, craniotomy/craniectomy, with or without evacuation of clot
was undertaken in 45 patients, (42.9%) and ICP monitoring, in 37 patients (35.2%),
were the most common, followed by placement of external ventricular drain (EVD) and
elevation of depressed fracture in 2.9% and 3.8%, respectively. Previous studies found
the most common interventions to be craniotomy/craniectomy for hematoma evacuation
(37%–48%), placement of EVD (19%–47%), followed by fracture elevation (13%–23%).[11 ]
[17 ]
[20 ]
The overall mortality in our study was found to be 14.3%. It is on the higher end
of the spectrum, with many studies reporting only up to 1%–7%.[8 ]
[21 ]
[22 ]
[23 ] However, mortality more than 10% was reported in populations of Sweden, Spain, UK,
and South Africa.[12 ]
[16 ]
[24 ]
[25 ] It would depend on multiple factors, including the severity of the injury, time
to emergency response and level of care and infrastructure available. Mortality is
higher in our study, because severe head injury at admission constituted maximum number
of cases.
From our study, factors independently associated with mortality on multivariate analysis
were postresuscitation GCS ≤ 8, whereas post resuscitation GCS ≤ 8 on admission and
NICU stay of >7 days were independent factors predicting poor outcome. Various studies
have identified low GCS as a risk factor for death and poor outcome.[4 ]
[26 ]
[27 ]
[28 ]
[29 ]
[30 ] Monitoring closely and early interventions may be justified in children with head
injury with low GCS scores. Young age and diffuse edema on CT in our study were identified
as other factors in multivariate analysis but were not found to be statistically significant.
Age and mortality have a controversial effect. Some studies reported age and outcome
to be related, whereas some studies found survival was independent of age.[26 ]
[27 ]
[30 ]
[31 ]
[32 ] Diffuse brain edema is also a common factor associated with mortality and poor outcome.[26 ]
[28 ]
[29 ] Prolonged NICU stay may be attributed to the severity of injury and patients requiring
neurosurgical interventions.
Limitations of our study are that it is a single-center retrospective study with a
small sample size. GOS at discharge was noted and patients were not followed-up at
after the discharge due to the retrospective nature of the study. Neurobehavioral
and psychosomatic changes and symptoms which might occur during the course could have
identified at long-term follow-up. We did not study the postresuscitation pupil size
and reactivity, which could have been more informative.
Conclusion
TBI was commonly seen in children less than 4 years of age with female dominance.
Males suffered more than females at an older age. Majority of the pediatric TBI were
due to falls, with RTA slowly growing. A factor independently associated with mortality
was postresuscitation GCS ≤ 8. Poor outcome (GOS ≤ 3) was independently associated
with postresuscitation GCS ≤ 8 and NICU stay > 7 days. Despite advances in neurointensive
care, mortality and morbidity remains high in pediatric head trauma patients who present
with lower GCS. Pediatric TBI needs to be recognized as global health issue, warranting
shifts in research and clinical practice to improve care for TBI patients.
