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Elevated admission international normalized ratio strongly predicts mortality in victims of abusive head trauma
Christine M Leeper1, Isam Nasr, Christine McKenna
1From the Children's Hospital of Pittsburgh (C.M.L., C.M., R.P.B., B.A.G.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of General Surgery and Trauma (C.M.L.), Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and Division of Pediatric Surgery (I.N.), The Johns Hopkins Hospital, Baltimore, Maryland.
Insights
Elevated admission international normalized ratio (INR) in abusive head trauma patients significantly predicts mortality. Early intervention for these critically injured children is crucial for improving outcomes.
Area of Science:
- Pediatric Trauma
- Abusive Head Trauma
- Coagulation Disorders
Background:
- Abusive head trauma (AHT) in children leads to severe outcomes, often with diagnostic delays due to non-verbal patients.
- Early identification and intervention are critical for improving prognosis in AHT victims.
Purpose of the Study:
- To determine if admission coagulation status, specifically international normalized ratio (INR), predicts mortality in pediatric AHT patients.
- To identify AHT patients who may benefit from early aggressive management.
Main Methods:
- Retrospective review of a Level 1 pediatric trauma registry (2005-2014).
- Included pediatric patients (0-17 years) with AHT; excluded those with pre-existing coagulation disorders or immediate death.
- Analyzed mortality, blood transfusion, and neurosurgical intervention rates, using logistic regression to control for known outcome predictors.
Main Results:
- 35% of AHT patients had an admission INR ≥ 1.3, associated with hypothermia, hypotension, acidosis, and lower Glasgow Coma Scale (GCS) scores.
- Overall mortality was 24.8%, with 60% mortality in patients with INR ≥ 1.3 versus 6% in those with INR ≤ 1.3 (p < 0.001).
- Admission INR ≥ 1.3 was the strongest independent predictor of mortality (AOR 5.27-6.25, p < 0.007) and predicted need for early transfusion and neurosurgery.
Conclusions:
- An admission INR of 1.3 or greater is a strong predictor of mortality in pediatric abusive head trauma.
- Patients with elevated INR require targeted, aggressive early interventions and monitoring.
- Further research into therapeutic targets for trauma-induced coagulation dysregulation is warranted.
Background:
Victims of abusive head trauma have poor outcomes compared with other injured children. There is often a delay in diagnosis because these young patients are unable to communicate with health care providers. These critically injured patients would benefit from early identification and therapy.
Methods:
We performed a retrospective review of our single hospital trauma registry from 2005 to 2014. All Level 1 pediatric (age 0-17 years) trauma patients who sustained abusive head trauma were included. Exclusion criteria included no admission coagulation studies, prehospital product transfusion, preexisting coagulation disorder, or death upon arrival. Primary outcome was mortality; secondary outcomes were early blood transfusion and neurosurgical intervention. Univariate analysis included Fisher's exact and Wilcoxon rank-sum testing; we then performed logistic regression modeling and calculated adjusted odds ratios (AORs) to control for known predictors of poor outcome including hypotension, hypothermia, acidosis, Injury Severity Score (ISS), and head Abbreviated Injury Scale (AIS) score.
Results:
In 101 total subjects, 35% (n = 35) had international normalized ratio (INR) of 1.3 or greater at admission. On univariate analysis, patients with coagulation dysregulation were more likely to have hypothermia, hypotension, acidosis, high ISS, and low Glasgow Coma Scale (GCS) score (all p < 0.05). There was no difference in age, anemia, and incidence of polytrauma. Overall mortality was 24.8% (n = 25), which varied significantly based at admission INR (60% INR ≥ 1.3 vs. 6% INR > 1.3, p < 0.001). Patients with elevated INR were also more likely to have early packed red blood cell transfusion (p = 0.003) and neurosurgical intervention (p = 0.011). In logistic regression analysis, admission INR was the strongest independent predictor of mortality, with increased odds of 3.65 (p = 0.045). AOR after controlling specifically for hypotension, hypothermia, and acidosis was 6.25 (p = 0.006), and after controlling for head AIS score and admission GCS score, the AOR was 5.27 (p = 0.007).
Conclusion:
Admission INR of 1.3 or greater strongly predicts mortality in abusive head trauma. These patients should be targeted for early aggressive interventions and monitoring with the goal of improving patient outcomes. Further study is warranted to investigate potential therapeutic targets in trauma-induced coagulation dysregulation.
Level Of Evidence:
Prognostic and epidemiologic study, level III.
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