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Clinical Deterioration and Neurocritical Care Utilization in Pediatric Patients With Glasgow Coma Scale Score of 9-13
Elif Soysal1,2,3, Christopher M Horvat1,4, Dennis W Simon1,2,3,4,5,6,7,8,9
1Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.
Insights
A significant number of children with moderate traumatic brain injury (TBI) deteriorated to severe TBI within 48 hours. Higher Injury Severity Score and lower Glasgow Coma Scale scores predicted this decline in pediatric TBI patients.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Clinical Outcomes Research
Background:
- Moderate traumatic brain injury (TBI) in children requires careful monitoring for potential deterioration.
- Identifying predictive factors for TBI progression is crucial for timely intervention.
Purpose of the Study:
- To define clinical characteristics of hospitalized children with moderate TBI.
- To identify factors associated with deterioration to severe TBI in pediatric patients.
Main Methods:
- Retrospective cohort study of 177 pediatric patients with moderate TBI (Glasgow Coma Scale score 9-13).
- Data queried from National Trauma Data Bank and electronic health records.
- Deterioration defined as two Glasgow Coma Scale scores ≤8 within 48 hours.
Main Results:
- 21% of children with moderate TBI deteriorated to severe TBI within 48 hours.
- Deterioration was linked to increased intubation rates, specific CT findings (edema, subdural hematoma, contusion), and higher healthcare costs.
- Independent predictors of deterioration included higher Injury Severity Score, higher international normalized ratio, and lower admission Glasgow Coma Scale score.
Conclusions:
- A notable proportion of pediatric moderate TBI cases worsen, necessitating increased resource use and costs.
- Early identification of high-risk patients through Injury Severity Score, international normalized ratio, and admission Glasgow Coma Scale is vital for managing pediatric TBI.
Objectives:
To define the clinical characteristics of hospitalized children with moderate traumatic brain injury and identify factors associated with deterioration to severe traumatic brain injury.
Design:
Retrospective cohort study.
Setting:
Tertiary Children's Hospital with Level 1 Trauma Center designation.
Patients:
Inpatient children less than 18 years old with an International Classification of Diseases code for traumatic brain injury and an admission Glasgow Coma Scale score of 9-13.
Measurements And Results:
We queried the National Trauma Data Bank for our institutional data and identified 177 patients with moderate traumatic brain injury from 2010 to 2017. These patients were then linked to the electronic health record to obtain baseline and injury characteristics, laboratory data, serial Glasgow Coma Scale scores, CT findings, and neurocritical care interventions. Clinical deterioration was defined as greater than or equal to 2 recorded values of Glasgow Coma Scale scores less than or equal to 8 during the first 48 hours of hospitalization. Thirty-seven patients experienced deterioration. Children who deteriorated were more likely to require intubation (73% vs 26%), have generalized edema, subdural hematoma, or contusion on CT scan (30% vs 8%, 57% vs 37%, 35% vs 16%, respectively), receive hypertonic saline (38% vs 7%), undergo intracranial pressure monitoring (24% vs 0%), were more likely to be transferred to inpatient rehabilitation following hospital discharge (32% vs 5%), and incur greater costs of care ($25,568 vs $10,724) (all p < 0.01). There was no mortality in this cohort. Multivariable regression demonstrated that a higher Injury Severity Score, a higher initial international normalized ratio, and a lower admission Glasgow Coma Scale score were associated with deterioration to severe traumatic brain injury in the first 48 hours (p < 0.05 for all).
Conclusions:
A substantial subset of children (21%) presenting with moderate traumatic brain injury at a Level 1 pediatric trauma center experienced deterioration in the first 48 hours, requiring additional resource utilization associated with increased cost of care. Deterioration was independently associated with an increased international normalized ratio higher Injury Severity Score, and a lower admission Glasgow Coma Scale score.
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