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The effect of hypotension and hypoxia on children with severe head injuries
F A Pigula1, S L Wald, S R Shackford
1Department of Surgery, College of Medicine, University of Vermont, Burlington.
Insights
Hypotension, not hypoxia, significantly increases mortality in children with severe head injuries. Combined hypotension and hypoxia do not worsen outcomes compared to hypotension alone in pediatric head trauma patients.
Area of Science:
- Pediatric critical care medicine
- Neurotrauma research
- Emergency medicine
Background:
- Children with severe head injuries (Glasgow Coma Scale score < 8) generally have better survival rates than adults.
- The impact of hypotension (HT) and hypoxia (H) on pediatric head injury outcomes is not well-established.
- Previous studies indicate HT and H worsen outcomes in adult head trauma patients.
Purpose of the Study:
- To investigate the effects of hypotension and hypoxia on mortality in children with severe head injuries.
- To compare outcomes in pediatric patients with isolated HT, isolated H, combined HT and H, and neither condition.
- To determine if age-related protective mechanisms exist in pediatric head trauma regarding HT and H.
Main Methods:
- Prospective evaluation of 58 children with severe head injuries (GCS < 8) over 5 years.
- Classification of patients into groups based on systolic blood pressure (SBP < 90 mm Hg for HT) and arterial blood gases (PaO2 < 60 mm Hg for H).
- Analysis of data from the National Pediatric Trauma Registry, including the institution's cohort (total 509 children), to validate findings.
Main Results:
- Children with neither hypoxia nor hypotension had a fourfold increased survival rate compared to those with either condition (P < .001).
- Hypotension significantly increased mortality in pediatric head injury patients, even without hypoxia (P < .00001).
- Hypoxia alone did not significantly increase mortality in normotensive patients (P = .34). Combined HT and H showed only a slight increase in mortality over HT alone (P = .056).
Conclusions:
- Hypotension is a critical factor driving increased mortality in head-injured children.
- The detrimental effects of hypotension in pediatric head trauma negate age-related survival advantages, bringing outcomes closer to adult levels.
- Hypoxia alone appears less critical than hypotension in pediatric severe head injury mortality.
Abstract:
Survival of children (< 17 years) with severe head injuries (Glascow Coma Scale [GCS] score < 8) has been shown to be better than that of adults. The addition of hypotension (HT) or hypoxia (H) has a deleterious effect on outcome in adults but no information is currently available about their effects in children. Over a 5-year period, 58 children with GCS scores < 8 were admitted and prospectively evaluated at this institution. Patients were divided into two groups on the basis of systolic blood pressure (SBP) and arterial blood gasses. Patients exhibiting HT, defined as a SBP < 90 mm Hg, and patients demonstrating H with a PaO2 < 60 mm Hg were compared with normoxic, normotensive children. Survival was increased fourfold in patients with neither H nor HT as compared with children with either H or HT (P < .001). To validate these observations we reviewed the data from the National Pediatric Trauma Registry for similar patients and included our cohort in the analysis. In total, 509 children had sufficient data for analysis and were studied. Hypoxia alone was not associated with increased mortality in normotensive patients (P = .34). Hypotension significantly increased mortality in these children even without concomitant H (P < .00001). If both HT and H were found together, mortality was only slightly increased over those children with HT alone (P = .056). These data confirm that HT with or without H causes significantly increased mortality in head-injured children to those levels normally found in adults (P = .9), alleviating any age-related protective mechanisms normally afforded.(ABSTRACT TRUNCATED AT 250 WORDS)