Research Reports - The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury

J Trauma Acute Care Surg. 2013 Oct;75(5):836-42

Stewart TC, Alharfi IM, Fraser DD

BACKGROUND: The study objective was to describe the epidemiology of serious
concomitant injuries and their effects on outcome in pediatric severe traumatic
brain injury (sTBI).
METHODS: A retrospective cohort of all severely injured (Injury Severity Score
[ISS] ≥ 12) pediatric patients (<18 years) admitted to our pediatric intensive
care unit, between 2000 and 2011, after experiencing an sTBI (Glasgow Coma Scale
[GCS] score ≤ 8 and head Abbreviated Injury Scale [AIS] ≥ 4) were included. Two
groups were compared based on the presence of serious concomitant injuries
(maximum AIS score ≥ 3). Multivariate logistic regression was undertaken to
determine variable associations with mortality.
RESULTS: Of the 180 patients with sTBI, 113 (63%) sustained serious concomitant
injuries. Chest was the most commonly injured extracranial body region (84%),
with lung being the most often injured. Patients with serious concomitant
injuries had increased age, weight, and injury severity (p < 0.001) and were more
likely injured in a motor vehicle collision (91% vs. 48%, p < 0.001). Those with
serious concomitant injuries had worse sTBI, based on lower presedation GCS (p =
0.031), higher frequency of fixed pupils (p = 0.006), and increased imaging
abnormalities (SAH and DAI, p ≤ 0.01). Non-neurosurgical operations and blood
transfusions were more frequent in the serious concomitant injury group (p <
0.01). The differences in mortality for the two groups failed to reach
statistical significant (p = 0.053), but patients with serious concomitant
injuries had higher rates of infection and acute central diabetes insipidus,
fewer ventilator-free days, and greater length of stays (p < 0.05). Multivariate
analyses revealed fixed pupillary response (odd ratio [OR], 63.58; p < 0.001),
presedation motor GCS (OR, 0.23; p = 0.001), blood transfusion (OR, 5.80; p =
0.008), and hypotension (OR, 4.82; p = 0.025) were associated with mortality, but
serious concomitant injuries was not (p = 0.283).
CONCLUSION: Head injury is the most important prognostic factor in mortality for
sTBI pediatric patients, but the presence of serious concomitant injuries does
contribute to greater morbidity, including longer stays, more infections, fewer
ventilator-free days, and a higher level of care required on discharge from
LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

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