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Severe traumatic brain injury in children--are the results improving?
Jürg Pfenninger1, Alessandro Santi
1Pediatric Intensive Care Unit, University Children's Hospital, Inselspital, Bern, Switzerland. gurtner.seifriz@insel.ch
Insights
Pediatric traumatic brain injury (TBI) outcomes remain stable despite evolving intensive care. Initial injury severity, not advanced treatments, significantly impacts long-term results in children with severe TBI.
Area of Science:
- Pediatric neurosurgery
- Pediatric critical care
- Traumatology
Background:
- Traumatic brain injury (TBI) is a major cause of death and disability in children.
- Medical management strategies for TBI are continually evolving.
- Previous studies established baseline outcomes for comparison.
Purpose of the Study:
- To analyze recent data on severe blunt TBI in children.
- To compare current outcomes with historical patient series from 1978-1983 and 1988-1992.
- To evaluate the impact of changing management policies on pediatric TBI outcomes.
Main Methods:
- Retrospective analysis of 51 children (1 month to 16 years) with severe blunt TBI (Glasgow Coma Scale [GCS] <8).
- Data collected from 1994 to 1998.
- Outcomes assessed using the Glasgow Outcome Scale (GOS) 6-12 months post-injury.
Main Results:
- 69% of patients achieved a good outcome (GOS 4-5); 31% had a bad outcome (GOS 1-3).
- Factors associated with poor outcomes included low admission GCS, fixed dilated pupils, absent basal cisterns on CT, and coagulopathy.
- Despite less aggressive intensive care, the good outcome rate remained similar to previous series (69% vs. 60%).
Conclusions:
- Pediatric TBI outcomes were comparable to historical data despite changes in management.
- The severity of the primary injury appears to be the most critical factor influencing final outcome.
- Intensive care management plays a secondary role in determining the long-term results of severe pediatric TBI.
Questions Under Study:
Traumatic brain injury (TBI) remains an important cause of mortality and morbidity in children. Medical management is constantly being refined, and thus results should improve. The aim of the present study was to analyse our data of recent years and to compare them with previous series (1978-83 and 1988-92).
Patients And Methods:
The data of 51 children (1 month to 16 years old) with severe blunt TBI treated in our unit from 1994 to 1998 were analyzed retrospectively. Severe TBI was defined by immediate loss of consciousness and an admission Glasgow coma scale (GCS) <8. Outcome was classified by using the Glasgow outcome scale (GOS) 6 to 12 months after injury.
Results:
35 patients (69%) showed a good outcome (GOS 4 and 5), 14 died (GOS 1), one survived in a permanent vegetative state (GOS 2), and another was severely disabled (GOS 3) (GOS 1-3 = bad outcome, 31%). Bad outcome was associated with low GCS (i.e. 3 and 4), fixed and dilated pupils at admission, invisible basal cisterns on first computerized tomography, and presence of coagulopathy. Moderate to severe intracranial hypertension was also significantly related to bad outcome in the 26 patients with intracranial pressure monitoring. Compared to our first series severity of TBI was unchanged, and the incidence of multiple injury and consumption coagulopathy was less frequent. Intubation rate prior to admission to the centre increased from 35% to 94%. Intensive care measures (duration of mechanical ventilation, use of hypothermia, mannitol, thiopentone etc.) were less aggressive. The rate of good outcome remained unchanged (69% vs. 60%).
Conclusions:
Despite changing management policies, results were comparable with those of our former series. This fact underlines the importance of primary injury and the secondary role of intensive care management on final outcome.