The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution

Association of initial assessment variables and mortality in severe pediatric traumatic brain injury

Background

Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality.

Methods

Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression.

Results

Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%.

Conclusions

Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.

The role of fibrinogen in traumatic brain injury: from molecular pathological mechanisms to clinical management

Fibrinogen is the substrate of plasma coagulation. It plays an important role in the formation of reticular network, which is crucial to the strength and stability of blood clots. In addition to directly participating in coagulation, fibrinogen also participates in the destruction of blood-brain barrier and neuroinflammation. This article reviews the pathophysiological changes of fibrinogen after traumatic brain injury. Considerable efforts have been made to understand the mechanisms by which fibrinogen damages the central nervous system. Combined with the latest research hotspots, potentially promising treatment strategies at the molecular level were discussed. We believe that understanding the role of fibrinogen-mediated damage in nerve and blood-brain barrier function will enable timely intervention in patients with nerve damage, and guide the development of novel targeted therapeutics.

Management of Severe Traumatic Brain Injury in Pediatric Patients

The optimal management of severe traumatic brain injury (TBI) in the pediatric population has not been well studied. There are a limited number of research articles studying the management of TBI in children. Given the prevalence of severe TBI in the pediatric population, it is crucial to develop a reference TBI management plan for this vulnerable population. In this review, we seek to delineate the differences between severe TBI management in adults and children. Additionally, we also discuss the known molecular pathogenesis of TBI. A better understanding of the pathophysiology of TBI will inform clinical management and development of therapeutics. Finally, we propose a clinical algorithm for the management and treatment of severe TBI in children using published data.

Application of coagulation parameters at the time of necrotizing enterocolitis diagnosis in surgical intervention and prognosis

Purpose

It has been shown that abnormalities of coagulation and fibrinolysis system are involved in the pathogenesis of necrotizing enterocolitis (NEC), but not well studied challenge in the context of early detection of disease progression. The present study mainly explores the predictive significance of coagulation parameters at the time of NEC diagnosis in identifying the patients who eventually received surgery and/or NEC-related deaths.

Methods

The retrospective study of 114 neonates with NEC was conducted with assessments of demographic data, laboratory results at the time of NEC diagnosis, treatment methods and prognosis. According to treatment methods, patients were divided into surgical intervention group and medical treatment group. Predictive factors were put forward and determined by receiver operating characteristic (ROC) curve analysis. An analysis of the surgical intervention and prognosis was performed.

Results

Of 114 patients, 46 (40.4%) cases received surgical intervention and 14 (12.3%) deaths. prothrombin time (PT), PT international normalized ratio, activated partial thromboplastin time (APTT), fibrinogen and platelet count at the time of NEC diagnosis were independently associated with surgical NEC. The APTT could identify patients at high risk for surgical NEC, with 67.39% sensitivity, 86.76% specificity, better than that of other serological parameters. Coagulopathy was found in 38.6% of all patients. For surgical intervention, the area under the ROC curve (AUC) of coagulopathy was 0.869 (95% confidence interval [CI]: 0.794 ~ 0.944, P < 0.001), with 82.61% sensitivity and 91.18% specificity, outperformed APTT (95% CI: 0.236 ~ 0.173, P = 0.001). Furthermore, the AUC for coagulopathy to predict mortality was 0.809 (95% CI: 0.725 ~ 0.877, P < 0.001), with 92.86% sensitivity and 69.0% specificity.

Conclusion

Coagulation parameters at the time of NEC diagnosis were conducive to early prediction of surgical NEC and -related deaths, which should be closely monitored in neonates at high risk of NEC and validated as a clinical decision-making tool.

Pediatric severe traumatic brain injury mortality prediction determined with machine learning-based modeling

INTRODUCTION

Severe traumatic brain injury (sTBI) is a leading cause of mortality in children. As clinical prognostication is important in guiding optimal care and decision making, our goal was to create a highly discriminative sTBI outcome prediction model for mortality.

METHODS

Machine learning and advanced analytics were applied to the patient admission variables obtained from a comprehensive pediatric sTBI database. Demographic and clinical data, head CT imaging abnormalities and blood biochemical data from 196 children and adolescents admitted to a tertiary pediatric intensive care unit (PICU) with sTBI were integrated using feature ranking by way of a forest of randomized decision trees, and a model was generated from a reduced number of admission variables with maximal ability to discriminate outcome.

RESULTS

In total, 36 admission variables were analyzed using feature ranking with variable weighting to determine their predictive importance for mortality following sTBI. Reduction analysis utilizing Borata feature selection resulted in a parsimonious six-variable model with a mortality classification accuracy of 82%. The final admission variables that predicted mortality were: partial thromboplastin time (22%); motor Glasgow Coma Scale (21%); serum glucose (16%); fixed pupil(s) (16%); platelet count (13%) and creatinine (12%). Using only these six admission variables, a t-distributed stochastic nearest neighbor embedding algorithm plot demonstrated visual separation of sTBI patients that lived or died, with high mortality predictive ability of this model on the validation dataset (AUC = 0.90) which was confirmed with a conventional area-under-the-curve statistical approach on the total dataset (AUC = 0.91; P < 0.001).

CONCLUSIONS

Machine learning-based modeling identified the most clinically important prognostic factors resulting in a pragmatic, high performing prognostic tool for pediatric sTBI with excellent discriminative ability to predict mortality risk with 82% classification accuracy (AUC = 0.90). After external multicenter validation, our prognostic model might help to guide treatment decisions, aggressiveness of therapy and prepare family members and caregivers for timely end-of-life discussions and decision making.

LEVEL OF EVIDENCE

III; Prognostic.

Coagulation Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference

CONTEXT

Previous criteria for coagulation dysfunction in critically ill children were based mainly on expert opinion.

OBJECTIVE

To evaluate current evidence regarding coagulation tests associated with adverse outcomes in children to inform criteria for coagulation dysfunction during critical illness.

DATA SOURCES

Electronic searches of PubMed and Embase were conducted from January 1992 to January 2020 by using a combination of medical subject heading terms and text words to define concepts of coagulation dysfunction, pediatric critical illness, and outcomes of interest.

STUDY SELECTION

Studies were included if critically ill children with coagulation dysfunction were evaluated, if performance characteristics of assessment and/or scoring tools to screen for coagulation dysfunction were evaluated, and if outcomes related to mortality or functional status, organ-specific outcomes, or other patient-centered outcomes were assessed.

DATA EXTRACTION

Data were abstracted from each eligible study into a standard data extraction form, along with risk of bias assessment, by a task force member.

RESULTS

The systematic review supports the presence of at least 2 of the following criteria reflecting coagulation dysfunction in the absence of liver dysfunction: platelet count <100 000 cells per μL, international normalized ratio >1.5, fibrinogen level <150 mg/dL, and D-dimer value above 10 times the upper limit of normal, or above the assay's upper limit of detection if this limit is below 10 times the upper limit of normal.

LIMITATIONS

The proposed criteria for coagulation dysfunction are limited by the available evidence and will require future validation.

CONCLUSIONS

Validation of the proposed criteria and identified scientific priorities will enhance our understanding of coagulation dysfunction in critically ill children.

Predictors of In-Hospital Mortality for Road Traffic Accident-Related Severe Traumatic Brain Injury

(1) Background: Road traffic accidents (RTAs) are the leading cause of pediatric traumatic brain injury (TBI) and are associated with high mortality. Few studies have focused on RTA-related pediatric TBI. We conducted this study to analyze the clinical characteristics of RTA-related TBI in children and to identify early predictors of in-hospital mortality in children with severe TBI. (2) Methods: In this 15-year observational cohort study, a total of 618 children with RTA-related TBI were enrolled. We collected the patients' clinical characteristics at the initial presentations in the emergency department (ED), including gender, age, types of road user, the motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and the intracranial computed tomography (CT) Rotterdam score, as potential mortality predictors. (3) Results: Compared with children exhibiting mild/moderate RTA-related TBI, those with severe RTA-related TBI were older and had a higher mortality rate (p < 0.001). The in-hospital mortality rate for severe RTA-related TBI children was 15.6%. Compared to children who survived, those who died in hospital had a higher incidence of presenting with hypothermia (p = 0.011), a lower mGCS score (p < 0.001), a longer initial prothrombin time (p < 0.013), hyperglycemia (p = 0.017), and a higher Rotterdam CT score (p < 0.001). Multivariate analyses showed that the mGCS score (adjusted odds ratio (OR): 2.00, 95% CI: 1.28-3.14, p = 0.002) and the Rotterdam CT score (adjusted OR: 2.58, 95% CI: 1.31-5.06, p = 0.006) were independent predictors of in-hospital mortality. (4) Conclusions: Children with RTA-related severe TBI had a high mortality rate. Patients who initially presented with hypothermia, a lower mGCS score, a prolonged prothrombin time, hyperglycemia, and a higher Rotterdam CT score in brain CT analyses were associated with in-hospital mortality. The mGCS and the Rotterdam CT scores were predictive of in-hospital mortality independently.

Effects of Yunanan Baiyao adjunct therapy on postoperative recovery and clinical prognosis of patients with traumatic brain injury: A randomized controlled trial

BACKGROUND

Effective therapies are needed to prevent the secondary injury and poor prognosis associated with emergency craniotomy of traumatic brain injury (TBI).

HYPOTHESIS/PURPOSE

The wound-healing medicine Yunnan Baiyao (YB) and Xingnaojing (XNJ) adjunct-therapy may improve the outcome of orthodox mono-therapy (OT).

STUDY DESIGN

Randomized controlled trial.

METHODS

Eighty patients with moderate-to-severe TBI received emergency craniotomy (within 12 h after TBI) at the Chinese PLA General Hospital before being randomly assigned to 4 different treatments (n = 20) for 7 days: 1) OT; 2) OT+XNJ (i.v. 20 ml/daily); 3) OT+low dose-YB (oral, 1,000 mg/day); 4) OT+high dose-YB, 2,000 mg/day).

RESULTS

GCS score was improved more quickly and became significantly higher in XNJ, l-YB, h-YB groups than in OT group (p<0.01). Serum S100B peaked higher but declined more slowly in OT group than in other groups (p<0.01). On postoperative Day 7, S100B was 20% below baseline in YB and XNJ groups but remained 19% above baseline in OT group which also lost 38% of superoxide dismutase (SOD) activity on Day 3 and recovered 69% of SOD on Day 7 whereas the YB and XNJ groups lost 16%∼23% of SOD activity on Day 3 and recovered 92%∼99% of SOD on Day 7 (p<0.01). Clinical prognosis (Glasgow Outcome Scale and Karnofsky Performance Scale) were significantly better (25%∼30%) in the XNJ, l-YB and h-YB groups than in OT group 3 months post-surgery and were correlated with serum S100B and SOD.

CONCLUSIONS

YB and XNJ adjunct therapies improved postoperative recovery and clinical prognosis in patients with moderate-to-severe TBI partly through divergent regulation of S100B and SOD pathways. (The trial was registered at Chinese Clinical Trial Registry (ChiCTR) trial registration number: ChiCTR2000030280).

Traumatic Brain Injury-Related Pediatric Mortality and Morbidity in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The burden of pediatric traumatic brain injury (pTBI) in low- and middle-income countries (LMICs) is unknown. To fill this gap, we conducted a review that aimed to characterize the causes of pTBI in LMICs, and their reported associated mortality and morbidity.

METHODS

A systematic review was conducted. MEDLINE, Embase, Global Health, and Global Index Medicus were searched from January 2000 to May 2020. Observational or experimental studies on pTBI of individuals aged between 0 and 16 years in LMICs were included. The causes of pTBI and morbidity data were descriptively analyzed, and case fatality rates were calculated.

PROSPERO ID

CRD42020171276.

RESULTS

A total of 136 studies were included. Fifty-seven studies were at high risk of bias. Of the remaining studies, 170,224 cases of pTBI were reported in 32 LMICs. The odds of having a pTBI were 1.8 times higher (95% confidence interval, 1.6-2.0) in males. The odds of a pTBI being mild were 4.4 times higher (95% confidence interval, 1.9-6.8) than a pTBI being moderate or severe. Road traffic accidents were the most common cause (n = 16,275/41,979; 39%) of pTBIs. On discharge, 24% of patients (n = 4385/17,930) had a reduction in their normal mental or physical function. The median case fatality rate was 7.3 (interquartile range, 2.1-7.7).

CONCLUSIONS

Less than a quarter (n = 32) of all LMICs have published high-quality data on the volume and burden of pTBI. From the limited data available, young male children are at a high risk of pTBIs in LMICs, particularly after road traffic accidents.

Predictors of In-Hospital Mortality for School-Aged Children with Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of mortality in children. There are few studies focused on school-aged children with TBI. We conducted this study to identify the early predictors of in-hospital mortality in school-aged children with severe TBI. In this 10 year observational cohort study, a total of 550 children aged 7-18 years with TBI were enrolled. Compared with mild/moderate TBI, children with severe TBI were older; more commonly had injury mechanisms of traffic accidents; and more neuroimage findings of subarachnoid hemorrhage (SAH), subdural hemorrhage (SDH), parenchymal hemorrhage, cerebral edema, and less epidural hemorrhage (EDH). The in-hospital mortality rate of children with severe TBI in our study was 23%. Multivariate analysis showed that falls, being struck by objects, motor component of Glasgow coma scale (mGCS), early coagulopathy, and SAH were independent predictors of in-hospital mortality. We concluded that school-aged children with severe TBI had a high mortality rate. Clinical characteristics including injury mechanisms of falls and being struck, a lower initial mGCS, early coagulopathy, and SAH are predictive of in-hospital mortality.

Non-neurologic organ dysfunction plays a major role in predicting outcomes in pediatric traumatic brain injury

BACKGROUND

Nonneurological organ dysfunction (NNOD) occurs after traumatic brain injury (TBI) and is associated with mortality. The aim of our study was to evaluate the prevalence of NNOD and its association with outcomes in pediatric patients with TBI. We hypothesized that NNOD is associated with worse outcomes in pediatric patients with severe TBI.

METHODS

We performed a 4-year (2013-16) analysis of our prospectively maintained TBI database. All patients (age < 18) with an isolated-severe TBI (head-abbreviated injury scale: AIS ≥ 3 & extracranial-AIS < 3) were included. NNOD was measured using the pediatric multiple organ dysfunction (P-MOD) score. Outcomes were in-hospital mortality, Glasgow Outcome Scale-Extended (GOS-E), and adverse discharge disposition: rehabilitation or skilled nursing facility (SNF). Regression analysis was performed.

RESULTS

We analyzed 292 patients. Mean age was 11 ± 6 years, 57% were male and the mortality rate was 18.1%. The incidence of NNOD was 35%. The most common dysfunctional organ system was the respiratory (25%) followed by the cardiovascular (12%). On regression analysis, the presence of at least one NNOD was independently associated with in-hospital mortality (OR 2.1 [1.7-2.9]; p < 0.01), low GOS-E (OR 1.8 [1.5-2.3]; p < 0.01), and SNF disposition (OR 1.7 [1.2-2.1]; p < 0.01).

CONCLUSION

NNOD develops in one of every three severe TBI pediatric patients and is independently associated with adverse outcomes. Identification of NNOD in pediatric TBI and focusing on management of NNOD could improve outcomes.

LEVEL OF EVIDENCE

III Prognostic.

Early coagulopathy in children with isolated blunt head injury is associated with mortality and poor neurological outcomes

OBJECTIVE

Traumatic brain injury (TBI) is the leading cause of long-term disability and death in children and adolescents globally. Long-term adverse outcomes, including physical, cognitive, and behavioral sequelae, have been reported after TBI in a significant number of pediatric patients. In this study the authors sought to investigate the epidemiology of TBI-associated coagulopathy and its association with mortality and poor neurological outcome in a pediatric population with isolated moderate to severe blunt head injury treated at the authors' institution.

METHODS

This retrospective study was conducted in the children's emergency department between January 2010 and December 2016. Children < 18 years old who presented with isolated moderate to severe blunt head injury were included in the study. The authors collected data on patient demographics, clinical presentation, and TBI management. Outcomes studied were death and poor neurological outcome defined by a score of < 7 (death, moderate to severe neurological disability) at 6 months postinjury on the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds).

RESULTS

In 155 pediatric patients who presented with isolated moderate to severe blunt head injury, early coagulopathy was observed in 33 (21.3%) patients during the initial blood investigations done in the emergency department. The mean (SD) age of the study group was 7.03 (5.08) years and the predominant mechanism of injury was fall from height (65.2%). The median Abbreviated Injury Scale of the head (AIS head) score was 4 and the median GCS score was 13 (IQR 12-15). TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 (p = 0.02, adjusted OR 6.07, 95% CI 1.32-27.83). The overall mortality rate was 5.8%. After adjusting for confounders, only AIS head score and hypotension at triage remained significantly associated with TBI-associated coagulopathy.

CONCLUSIONS

TBI-associated coagulopathy was independently associated with GOS-E Peds score < 7 at 6 months postinjury. Larger prospective studies are needed to investigate the use of TBI-associated coagulopathy to prognosticate these critical clinical outcomes.