[Effect of a lung contusion on the prognosis of severe head injury in the child]

Proper Partial Pressure of Arterial Oxygen for Patients with Traumatic Brain Injury

Background

The partial pressure of arterial oxygen (PaO₂) is critical to the outcome of patients with traumatic brain injury (TBI). However, it is not clear what range of PaO₂ should be maintained to improve patient outcome. The aim of this study was to explore the PaO₂ value needed in the acute phase of TBI and provide new evidence for clinical practice.

Material/Methods

A total of 153 patients with TBI were enrolled retrospectively. Univariate and multivariate logistic regression analyses were conducted on sex, Glasgow Coma Scale (GCS) score on admission, PaO₂ within 6 h of admission, oxygenation index, and other factors. The Glasgow Outcome Score (GOS) of the patient at discharge was used as an indicator of outcome. The good outcome group had GOS ≥4, and the poor outcome group had GOS <4.

Results

The 153 patients were divided into a good outcome group (n=62) and poor outcome group (n=91). There was a significant difference in sex, admission GCS, surgery, airway status, PaO₂, and oxygen index within 6 h of admission between the 2 groups. Logistic regression analysis showed that PaO₂ <60 mmHg, male sex, and admission GCS score of 3 to 12 were independent risk factors for a poor outcome.

Conclusions

Patients with TBI having PaO₂ <60 mmHg within 6 h after admission were more likely to have poor outcomes. The upper limit value of PaO₂ that affects the outcome of TBI in patients has not been found.

Traumatic brain injury in children with thoracic injury: clinical significance and impact on ventilatory management

PURPOSE

This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI).

METHODS

All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study.

RESULTS

A total of 75 patients with a median age of 11 [6-13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no difference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI.

CONCLUSION

In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence.

Impact of blunt chest trauma on outcome after traumatic brain injury- a matched-pair analysis of the TraumaRegister DGU®

Background

Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI.

Methods

We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TR-DGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3–5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AIS_Thorax= 2–5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ²-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05.

Results

A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AIS_Thorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI.

Conclusions

Chest trauma in general, regardless of its initial severity (AIS_Thorax= 2–5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered “at risk” and vigilance for the maintenance of optimal neuro-protective measures should be high.

"Perimortem" total body CT-scan examination in severely injured children: an informative insight into the causes of death

OBJECTIVE

To report routine practice of "perimortem" CT-scan imaging to determine the causes of death in children dying from severe accidental injuries within the first hours following hospital admission.

SETTINGS

Trauma center of a University Pediatric Hospital.

METHODS

A retrospective study was conducted in children (0 to 15 years old) referred for severe trauma (GCS ≤ 8) to a regional pediatric trauma center, presenting with at least spontaneous cardiac rhythm and dying within the first 12 h after admission. "Perimortem" CT-scan consisted in high-resolution, contrast-enhanced, full-body CT-scan imaging, performed whatever child's clinical status. Lethal and associated lesions found were analyzed and classified according to validated scales. The comparison between clinical and radiological examinations and CT-scan findings evaluated the accuracy of clinical examination to predict lethal lesions.

RESULTS

CT-scan performed in 73 children detected 132 potentially lethal lesions, at least 2 lesions in 63%, and 1 in 37% of the cases. More frequent lethal lesions were brain (43%), and chest injuries (33%), followed by abdominal (12%), and cervical spine injuries (12%). Clinical and minimal radiological examinations were poorly predictive for identifying abdominal/chest lesions. Clinical and imaging data provided to the medical examiner were considered sufficient to identify the cause of death, and to deliver early burial certificates in 70 children. Only three legal autopsies were commanded.

CONCLUSIONS

Perimortem CT imaging could provide an insight into the causes of death in traumatized children. Performed on an emergency basis near death, it eliminates the difficulties encountered in forensic radiology. It could be a possible alternative to full-scale forensic examination, at least regarding elucidation of the potential, or highly probable causes of death.

Factors Predicting Lung Contusions in Critically Ill Trauma Children: A Multivariate Analysis of 330 Cases

PURPOSE

The aim of the study was to identify factors predicting lung contusion in trauma children.

METHODS

Retrospective study conducted for a period of 8 years (January 01, 2005-December 31, 2012) in a medical surgical intensive care unit. All trauma patients younger than 15 years were included. Two groups were compared: those with lung contusions (C+ group) and those without lung contusions (C- group).

RESULTS

We included 330 patients. The mean (SD) age was 7.6 (4.3) years. Chest injury was diagnosed in 70 patients (21.2%). All our patients needed mechanical ventilation. Lung contusions were diagnosed in 43 patients (13% of all patients and 61.4% of patients with chest trauma). In multivariate analysis, independent factors predicting lung contusion were road traffic accident (odds ratio [OR], 3.2; 95% confidence interval [CI], 1.2-8.6; P = 0.019), increased Pediatric Risk of Mortality (PRISM) score (OR, 1.1; 95% CI, 1.1-1.2; P = 0.017), hepatic contusion (OR, 4.8; 95% CI, 1.3-17.1; P = 0.017), and pelvic ring fracture (OR, 3.5; 95% CI, 1.1-10.5; P = 0.026). Death occurred in 46 patients (13.9%). Intensive care unit mortality was significantly higher in the C+ group (OR, 2.5; 95% CI, 1.2-5.4; P = 0.021). However, mortality was not different between the 2 groups after adjusting for PRISM score (OR, 1.2; 95% CI, 0.5-2.9; P = 0.752) or after adjusting for Injury Severity Score (OR, 0.7; 95% CI, 0.3-2.1; P = 0.565).

CONCLUSIONS

Lung contusion is common in critically ill children with chest trauma. The diagnosis should be considered in patients with road traffic accident, increased PRISM score, hepatic contusion, and pelvic ring fracture.

Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale

BACKGROUND

Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to improve outcome.

OBJECTIVE

To identify the main predictors of mortality and to propose a grading scale to measure the risk of death.

METHODS

This retrospective study was based on medical records of children with severe traumatic brain injury who were hospitalized at a level I pediatric trauma center between January 2000 and December 2005. Multiple logistic regression analysis was done to identify independent factors related to mortality. A receiver-operating characteristics curve was performed to verify the accuracy of the multiple logistic regression, and associations that increased mortality were verified.

RESULTS

We identified 315 children with severe head injury. Median Glasgow Coma Scale score was 6, and median Pediatric Trauma Score was 4. Global mortality rate was 30%, and deaths occurred despite adequate medical management within the first 48 hours in 79% of the patients. Age < 2 years (P = .02), Glasgow Coma Scale ≤ 5 (P < 10), accidental hypothermia (P = .0002), hyperglycemia (P = .0003), and coagulation disorders (P = .02) were all independent factors predicting mortality. A prognostic scale ranging from 0 to 6 that included these independent factors was then calculated for each patient and resulted in mortality rates ranging from 1% with a score of 6 to 100% with a score of 0.

CONCLUSION

Independent and modifiable mortality predictors could be identified and used for a new grading scale correlated with the risk of mortality in pediatric traumatic brain injury.

Predictors of Outcomes in Traumatic Brain Injury

INTRODUCTION

The purpose of this study was to retrospectively evaluate patients treated for traumatic brain injuries (TBI) to determine how multiple organ trauma (MOT) and lung injuries sustained at the time of initial injury affect outcome.

METHODS

A single institution retrospective review of all patients diagnosed with TBI at a level I trauma center from 2000 to 2014 was conducted. Clinical outcome was based on Glasgow Outcome Scale at hospital discharge. Lung injury was defined as the presence of pulmonary contusions, pneumothorax, hemothorax, rib fractures, or diaphragmatic rupture proven by x-ray or computed tomography scan. MOT was defined as trauma to one body region with an Abbreviated Injury Scale (AIS) score ≥3 plus trauma to 2 additional body regions with AIS scores ≥1. Regression analysis was conducted with SPSS 21.

RESULTS

There were 409 patients reviewed. The majority of patients were male (73%), average age was 46 years (range, 16-94 years), average Glasgow Coma Scale (GCS) score was 7, and 71% had a severe TBI (GCS ≤8). Thirty percent of patients had poor outcome (Glasgow Outcome Scale = 1-2) Regression analysis indicated age (odds ratio [OR] 1.03, P < 0.001), initial GCS (OR 0.88, P < 0.001), Injury Severity Score (OR 1.03, P = 0.021), and head AIS ≥5 (OR 0.55, P = 0.019) were significant independent predictors of poor outcome. Sex, MOT, lung injury, and lung injury severity were not significant predictors of outcome.

CONCLUSIONS

Age, GCS, Injury Severity Score, and critical head injuries (AIS ≥5) were significant tools in predicting outcome in this patient cohort. MOT and traumatic lung injury may cause significant damage to a patient suffering from a severe TBI, but these injuries do not predict mortality in this patient population.

Impact of thoracic injury on traumatic brain injury outcome

Background

To assessed the significance of thoracic injury on the 30-day mortality and outcome of traumatic brain injury (TBI).

Methods

TBI patients admitted to our department were retrospectively evaluated. We developed two prognostic models based on admission predictors with logistic regression analysis to assess the significance of thoracic injuries in determining the 30-day mortality and outcome. The internal validity of the models was evaluated with the bootstrap re-sampling technique. We also validated the models in an external series of 165 patients that collected from our center. Discriminative ability was evaluated with C statistic. Calibrative ability was assessed with the Hosmer-Lemeshow test (H-L test).

Results

Among 505 TBI patients admitted, 102 (20.2%) had thoracic injuries. Patients with a PCS ≥6 had a 3.142 and 8.065 times higher odds of mortality and poor outcome compared with patients with a PCS <6, respectively. Any one-score increase of the TTS had a 1.193 times higher odds of a poor outcome (p = 0.017). The predictive model for mortality and 30-day functional outcome both had good accuracy (AUC: 0.875; 95% confidence interval [CI], 0.841–0.910 and AUC: 0.888; 95%CI, 0.860–0.916, respectively). Internal validation showed no over optimism in any of the two models’ predictive C statistics (C statistic 0.872 for 30-day mortality and C statistic 0.884 for the 30-day neurological outcome). The external validation confirmed the discriminatory ability of these models (C statistic 0.949 (95%CI: 0.919–0.980) for 30-day mortality and C statistic 0.915 (95%CI: 0.868–0.963) for the 30-day neurological outcome). The calibration was also good for patients from the validation population (H-L test p>0.05).

Conclusion

Thoracic injury diagnosed by CT has a negative impact on the 30-day mortality and functional outcome of TBI patients. The extent of PC and the TTS are the predictors for TBI outcome.

Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines

OBJECTIVE

To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation.

DESIGN

Observational study.

SETTING

Pediatric intensive care unit of a university hospital.

PATIENTS

A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8), with spontaneous cardiac rhythm.

INTERVENTIONS

Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed.

MEASUREMENTS AND MAIN RESULTS

After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35-40 torr, 4.6-5.3 kPa) in 70% of the cases upon arrival.

CONCLUSIONS

Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.

Pulmonary trauma

Pulmonary trauma is common and devastating and is associated with significant morbidity and mortality. The present review highlights recent literature and case reports in this area. Topics of particular significance or interest include mechanisms of injury, potentially fatal intrathoracic vascular injuries, anesthetic management, fluid management (crystalloids as well as hemoglobin-based oxygen-carrying solutions), pain management of severe chest trauma, surgical management, and novel methods of diagnosis.

Enhanced pulmonary inflammation following experimental intracerebral hemorrhage

The association between brain damage and respiratory dysfunction has been recognized although mechanistic link between the two is still poorly defined. Intracerebral hemorrhage is accompanied by brain injury, stroke, and parenchymal hematoma formation with surrounding inflammation. Increase intracranial pressure as a result of intracerebral hemorrhage may promote localized activation of cytokines and coagulation system including tissue factor release. However, whether intracerebral hemorrhage triggers inflammation in noncerebral organs has not been elucidated. The aim of the present study was to examine the impact of intracerebral hemorrhage on lung inflammatory response. Intracerebral hemorrhage was induced by stereotaxic intrastriatal administration of bacterial collagenase. Expression of intracellular adhesion molecule-1 (ICAM-1), IKB-alpha, tissue factor, tumor necrosis factor-alpha (TNF-alpha), and interleukin-1beta (IL-1beta) was evaluated by Western blot analysis. Our results revealed that intracerebral hemorrhage upregulated expression of ICAM-1 and tissue factor in both brain and lung, whereas it enhanced TNF-alpha and IL-1beta mainly in brain within 6 and 24 h of the brain injury. Levels of IKB-alpha remained unchanged in brain and lung tissues. Appearance of inflammatory markers in the lung was accompanied by morphological pulmonary damage. These data suggest that intracerebral hemorrhage may trigger acute inflammatory response in both brain and lung.

Pulmonary Contusion in Severe Head Trauma Patients

STUDY OBJECTIVE

To evaluate the impact on morbidity and mortality of pulmonary contusion in multiple-trauma patients with severe head trauma.

DESIGN

Matched-paired, case-control study

SETTING

ICU at a tertiary university hospital.

PATIENTS

During a 3-year period, 313 consecutive multiple-trauma patients with severe head trauma (Glasgow coma scale [GCS], </= 8) who were admitted to the ICU.

INTERVENTIONS

Case-control matching criteria were as follows: (1) age difference within 5 years; (2) sex; (3) GCS in two categories; (4) similar pattern of injury; and (5) simplified acute physiology score II in five categories. A pulmonary contusion, defined by the clinical context and the result of a chest CT scan, was diagnosed in 90 patients. Analysis was performed on 90 pairs who were matched with 100% success.

RESULTS

Ninety patients (29%) presented a diagnosis of pulmonary contusion. The presence of pulmonary contusion had an impact on the PaO(2)/fraction of inspired oxygen (FIO(2)) ratio, which was significantly reduced in patients with a pulmonary contusion. The ICU stay, the occurrence of complications such as nosocomial pneumonia or ARDS, the Glasgow outcome scale, and the mortality rate did not significantly differ between case patients and control subjects. Mortality also was not affected when patients were stratified according to the severity of the PaO(2)/FIO(2) ratio.

CONCLUSION

In the study patients, pulmonary contusion alters gas exchange but does not appear to increase the morbidity and mortality of multiple-trauma patients with head trauma. A sample-size effect may limit the interpretation of the study.

[Strategies diagnosis of polytraumatized adult patients with coma]

OBJECTIVE

To review the diagnostic strategy of management of multiple trauma patient during the first hours.

DATA SOURCES

Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years.

DATA SELECTION

The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected.

DATA SYNTHESIS

The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.