Published online June 29, 2009
PEDIATRICS Vol. 124 No. 1 July 2009, pp. 56-64 (doi:10.1542/peds.2008-1006)

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ARTICLE

Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury

Michelle Zebrack, MD^a, Christopher Dandoy, MD^b, Kristine Hansen, RN, BS^c, Eric Scaife, MD^d, N. Clay Mann, PhD, MS^e and Susan L. Bratton, MD, MPH^a

^a Divisions of Pediatric Critical Care
^d Pediatric Surgery
^e Intermountain Injury Control Research Center, University of Utah School of Medicine, Salt Lake City Utah
^b Division of Pediatrics, Miami Children's Hospital, Miami, Florida
^c Trauma Program, Primary Children's Medical Center, Salt Lake City, Utah

OBJECTIVES: Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during "early" (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge.

METHODS: This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care.

RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of "early care." Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension.

CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes.

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Key Words: traumatic brain injury • secondary brain injury • outcome • emergency department • emergency resuscitation • treatment • emergency medical services

Abbreviations: TBI—traumatic brain injury • ED—emergency department • PCMC—Primary Children's Medical Center • GCS—Glasgow Coma Scale • EMS—emergency medical services • ISS—Injury Severity Score • CT—computed tomography • GOS—Glasgow Outcome Scale • RR—relative risk • CI—confidence interval • aOR—adjusted odds ratio

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Accepted Nov 6, 2008.

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early resuscitation of children with TBi: are the goals being met ?

Philippe G Meyer, et al.

Pediatrics Online, 17 Jul 2009 [Full text]