Award: American Academy of Pediatrics Award
Authors: Duncan Trimble; Samantha Parker, MD; Liang Zhu, PhD; Charles Cox, MD; Ryan Kitagawa, MD; Stephen Fletcher, MD; David Sandberg, MD; Manish Shah, MD (Bellaire, TX)
Introduction: This study aims to assess outcomes of pediatric patients with blunt traumatic brain injury (TBI) presenting Glasgow Coma Scale (GCS) 3. Methods: We identified patients age 0-15 years with blunt TBI and a reported GCS 3 between 2007 and 2017 from a pediatric level 1 trauma center prospective registry. Exclusion criteria were cardiac death on arrival and penetrating injury. We reviewed clinical variables from patients with a non-pharmacologic GCS of 3 documented by a neurosurgical attending or resident. Importance of variables to survival was calculated. Results: A total of 88 patients (mean age 6.9 years) were included with a mortality rate of 68%. 12% had a poor long-term outcome (GOS 2 or 3) while 20% had a good long-term outcome (GOS 4 or 5). Mean follow-up was 2.8 years. Initial group comparison revealed those who survived presented with higher blood pressures (14% SBP <90 vs. 66% SBP>90, p<0.0001), higher initial temperatures (97.4° vs 94.9°, p=0.0002), lower mean Injury Severity Score (29.7 vs 39.5, p=0.003), less injury to other major organs (34% vs 61%, p=0.02), epidural hematomas (24% vs 7%, p=0.0359), less brain ischemia on CT (7% vs 39%, p=0.0017) and no brainstem injury (0% vs 27%, p=0.0019). Age, sex, race, mechanism of injury (MOI), Abbreviated Injury Score, midline shift, or time from injury to hospital did not significantly differ in group comparison between survivors and non-survivors. Classification tree analysis showed the most important variable for survival was pupillary exam; mortality was 83% in presence of bilateral, fixed dilated pupils. The relative importance of temperature, MOI, and hypotension to survivability was 0.79, 0.75, and 0.47, respectively. Conclusion: 20% of our pediatric non-pharmacologic GCS 3 cohort had a good functional outcome; pupillary exam, temperature, MOI, and hypotension correlated with survival . The data support selective aggressive management for these patients.