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ARTICLES: Michelle Zebrack, Christopher Dandoy, Kristine Hansen, Eric Scaife, N. Clay Mann, and Susan L. Bratton Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury Pediatrics 2009; 124: 56-64 [Abstract] [Full text] [PDF]

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

Philippe G Meyer, Sarah Ducrocq, Caroline Duracher, Thomas Baugnon, Stéphane Blanot   (17 July 2009)

early resuscitation of children with TBi: are the goals being met ? 17 July 2009
Philippe G Meyer, Staff Physician Pediatric Neuro critical Care Unit CHU Necker Paris, Sarah Ducrocq, Caroline Duracher, Thomas Baugnon, Stéphane Blanot Send letter to journal: Re: early resuscitation of children with TBi: are the goals being met ? philippe.meyer{at}nck.aphp.fr Philippe G Meyer, et al.	Sir, We were interested in the recent paper published in Pediatrics by Dr Zebrack et al. Analyzing 299 children with moderate to severe traumatic brain injuries referred to their centre after scene management by EMS, they concluded that documented hypotension and hypoxia during transport increases mortality and bad outcome (1). These findings have been underlined by Pigula, and Kokoska et al. (2,3), but did not find a solution more than ten years later. As underlined by the authors, this study suffers from several methodological limitations. The fact that 30% of patients were not fully monitored during transportation, but were finally considered as normotensive/nonhypoxic, even though they seemed to be the most severely injured, introduces a major bias. Moreover, only attempts, not effective correction of hypotension or hypoxia were required from scene/community hospital care providers, and these attempts were not evaluated in terms of efficiency, to achieve a rating of “treated”. In hypotensive patients, treatment was delayed until arrival in 86% of the cases. This could be assimilated to an intention-to-treat analysis introducing limitation that has been encountered in other studies dealing with EMS’ pediatric scene intubation practice (4). A more adequate method for analyzing factors influencing mortality and outcome could have been to consider the efficiently documented incidence of hypotension and hypoxia during “scene” management, the efficiency of therapeutic interventions performed during transportation, and finally the influence of persisting hypotension, hypoxia, and hypercarbia upon arrival on outcome in fully monitored patients. We think that the conclusion that attempts, made in this study, to treat these situations significantly improve outcome is not adequately supported by the results of this study. In our previous experience, including 585 children with severe TBI, we found similar epidemiological data with the exception that 19% of children less than 2-years who carried a higher risk of mortality (39% vs 21%) were included in our study. Our mean ISS (28), age (7y), and transport time (120 minutes) were very similar to those reported in this study (5). Persistent hypotension, and need for massive transfusion upon arrival were independent factors of increased mortality and bad outcome were more frequently noted in children less than 2-years. The main differences between these 2 studies could be found into interventions performed at the scene, and median GCS noted upon arrival. In Dr Zebrack’s patients, a GCS 3-4, despite a 23% incidence of normal CT-scan findings, contrasted with a median GCS of 6, with a 7% incidence of normal CT-scans, in ours. Another concern is the short length of stay in ICU (2 days) reported in patients with severe TBI defined by a median GCS of 4, and a relatively high rate of survival in patients with a median GCS 3. These patients with a GCS 4 had a surprising 30% incidence of normal CT - scan, questioning the diagnosis of severe TBI. This contrasted with our ICU length of 5.6 days in patients with a median GCS of 6, and a 90% death rate in patients with GCS 3. Regarding “scene” management, 98% of our patients were effectively intubated and continuously sedated, fluid loading (more than 20 ml/kg rapid IV infusion), and vasopressor infusion were used in respectively 65%, and 26%. This aggressive scene management resulted in a 7% incidence of persistent hypoxia in those with severe associated chest lesions, and a 31% incidence of hypotension upon arrival. Finally, global mortality (21 vs 22%) and increased risk of death related to hypotension were similar between the 2 studies. The conclusions easily drawn from this rough comparison could be that attempts at hypotension and hypoxia correction performed at the scene, could be sufficient, and at least as efficient as adequately performed advanced trauma life support interventions, in terms of mortality and outcome in children with severe TBI. It sounds like another recent conclusion that scene tracheal intubation should be generally avoided in pediatric trauma patient, since bag-mask ventilation could be as efficient as inadequately performed intubation in terms of mortality and outcome. After eliminating the confounding factors of increased transport time inherent to scene ATLS management, resulting in potentially delayed emergency surgical interventions (required in less than 7% of our patients), and complications of tracheal intubation performed by untrained care providers, the concept of golden hour, and the need for implementing guidelines for early management of pediatric TBI could be further questioned. This could be the best way to accept for the next ten years the assertion that needs will still be far to be met in early management of pediatric TBI, as it was concluded by Seidel et al. in the 80’s (6). More reasonably, conclusion should be that standardized methods of evaluation, taking objectively into account the ability of care providers to perform adequately these manoeuvres at the scene, and their efficiency in terms of prevention of secondary brain insults of systemic origin, mortality, and outcome are still lacking. They should be developed to compare efficiently two different systems, and to improve outcome of TBI in children. 1 Zebrack M, Dandoy C, Hansen K, Scaife E, Mann C, Bratton SL. Early resuscitation of children with moderate to severe traumatic brain injury. Pediatrics 2009; 124: 56-64. 2 Pigula FA, Wlad SL, Shackford SR, Wane DW. The effects of hypotension and hypoxia on children with severe head injuries. J Pediatr Surg. 1993; 28: 310- 316. 3 Kokoska ER, ER, Smith GS, Pittman T, Weber TR. Early hypotension worsens neurological outcome in pediatric patients with moderately severe head injuries. J pediatr Surg. 1998; 33:333-338. 4 Gausche M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, Poore PD, McCollough MD, Henderson DP, Pratt FD, Seidel JS. Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial. JAMA. 2000; 283:783-90. 5 Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A, Renier D, Carli P. epidemiology and early predictive factors of mortality and outcome in children with severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care 2006; 7: 461-7. 6 Seidel JS, Hornbein M, Yoshiyama K, Kuznets D, Finklestein JZ, St Geme JW Jr. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics. 1984;73:769-72. Conflict of Interest: None declared