Epidemiology of traumatic brain injury in children receiving intensive care in the UK

Aims: To describe the epidemiology of children with traumatic brain injury (TBI) admitted to paediatric intensive care units (PICUs) in the UK. Methods: Prospective collection of clinical and demographic information from paediatric and adult intensive care units in the UK and Eire between February 2001 and August 2003. Results: The UK prevalence rate for children (0–14 years) admitted to intensive care with TBI between February 2001 and August 2003 was 5.6 per 100 000 population per year (95% Poisson exact confidence intervals 5.17 to 6.05). Children admitted to PICUs with TBI were more deprived than the population as a whole (mean Townsend score for TBI admissions 1.19 v 0). The commonest mechanism of injury was a pedestrian accident (36%), most often occurring in children over 10. There was a significant summer peak in admissions in children under 10 years. Time of injury peaked in the late afternoon and early evening, a pattern that remained constant across the days of the week. Injuries involving motor vehicles have the highest mortality rates (23% of vehicle occupants, 12% of pedestrians) compared with cyclists (8%) and falls (3%). In two thirds of admissions (65%) TBI was an isolated injury. Conclusions: TBI in children requiring intensive care is more common in those from poorer backgrounds who have been involved in accidents as pedestrians. The summer peak in injury occurrence for 0–10 year olds and late afternoon timing give clear targets for community based injury prevention.     

Epidemiology of traumatic brain injury in children and adolescents in south-western Sweden

Abstract The objectives of this study were to outline the incidence, gender distribution, external causes, severity and early outcome of traumatic brain injury (TBI). The subjects were children and adolescents in the southwestern Swedish health care region, aged 0–17 y in 1987–1991 and fulfilling the criteria for TBI. Identification was made from the discharge registers of the hospitals in the region admitting patients with TBI, and outcome data were obtained from medical records. The mean incidence rate was 12/100 000 for TBI. The dominant external cause was traffic (60%), followed by falls (22%). At discharge, 49% of those surviving were healthy, 48% suffered from one functional impairment and 52% suffered from two or more impairments. In conclusion, although the incidence rate of TBI is low in Sweden, the condition causes permanent functional impairment in 6/100 000 cases every year.     

Mild traumatic brain injury in children

Head injury occurs frequently in childhood and results in approximately 500,000 emergency department visits and over $1 billion in costs annually. Nearly 75% of these children are ultimately diagnosed with mild traumatic brain injury (MTBI), a misnomer because many will have radiographically identified intracranial injuries and long-term consequences. Identification of the brain at risk and prevention of secondary injury is associated with the largest reduction in head trauma morbidity and mortality. This article reviews the current literature to discuss the initial evaluation, management, and long-term outcomes in children sustaining MTBI.     

Neurocritical care and traumatic brain injury

The majority of severely head injured children will not require neurosurgery. For the pediatrician, the central question must be whether medical interventions are effective in limiting morbidity and treating the problem of cerebral oedema. However, in order to address this issue we need to give some thought to the system of care in which we practice, how we assess the severity of brain injury and whether, in regard to pathophysiology, responses in children are significantly different from those seen in adults. In this regard, this review highlights some of the recent pediatric neurocritical care literature and provides, for the clinician, a framework on which to base ones medical management of severe traumatic brain injury occurring in childhood.     

Performance monitoring in children following traumatic brain injury

Background:  Executive control deficits are common sequelae of childhood traumatic brain injury (TBI). The goal of the current study was to assess a specific executive control function, performance monitoring, in children following TBI.
Methods:  Thirty-one children with mild–moderate TBI, 18 with severe TBI, and 37 control children without TBI, of comparable age and sex, performed the stop signal task, a speeded choice reaction time task. On occasion, they were presented with a signal to stop their responses. Performance monitoring was defined as the extent of slowing in go-task reaction time following failure to stop responses.
Results:  The TBI group as a whole demonstrated less post-error slowing than did controls. This finding suggested impaired error monitoring performance. In addition, time since injury and socioeconomic status predicted less slowing after stopped responses.
Conclusions:  We suggest that alterations in performance monitoring expressed as the inability to notice, regulate and adjust behavior to changing situations are an effect of TBI in children.     

Predictors of outcome in children with hydrocarbon poisoning receiving intensive care

The retrospective study included 48 children between 8.5 months--10 years, admitted to the PICU of an urban, tertiary care, teaching hospital in northern India from January 1995 to December 2001. Eighteen (38%) patients were hypoxemic on arrival, of which 8 (45%) required mechanical ventilation. Compared to the non-hypoxemic children, the hypoxemic patients were more likely to have received gastric lavage before arrival to our center (Odds Ratio 23.2, 95% CI 2.4 - 560.7) and had higher frequency of severe respiratory distress and leucocytosis (Odds Ratio 8.0, 95% CI 1.79 -38.6). On multiple regression analysis, we could not identify any particular variable that could predict hypoxemia. Secondary pneumonia developed in 16 (33.3%), with the duration of PICU stay being longer in these patients as against those who did not (144 hours vs 72 hours, p <0.05). Two (4.2%) children died and one suffered hypoxic sequelae. Prior lavage, hypoxemia at admission, need for ventilation, secondary sepsis and ventilator related complications were associated with poor outcome.     

Ventilator induced lung injury in children in the intensive care

In dit proefschrift werd de relatie onderzocht tussen mechanische ventilatie (MV), inflammatie en longschade. Het proefschrift bevat zowel experimentele als klinische studies.     

创伤性颅脑损伤患儿营养支持研究进展

创伤性颅脑损伤患儿处于高度营养风险状态,合理的营养支持有助于患儿创伤后恢复以及减少相关并发症的发生。创伤后及时正确评估患儿胃肠功能状态,并制定合理的营养支持方案,是临床治疗成功的关键。文章就创伤性颅脑损伤患儿能量代谢特点、营养支持时机和途径,以及创伤后胃肠功能损伤作一综述,为更合理规范创伤性颅脑损伤患儿的营养管理,有效预防创伤后胃肠功能损伤提供依据和建议。     

Enhanced thrombin generation in patients receiving intensive care.

Thrombin-antithrombin III complex (TAT) concentration was measured in 27 control and 155 intensive care patients to (a) establish normal reference ranges, (b) measure thrombin generation in critically ill patients, and (c) determine the characteristics of the TAT assay for the diagnosis of disseminated intravascular coagulation (DIC) in children. The normal reference range was 1-4.3 micrograms/l (median 2.3 micrograms/l), and 89.7% of patients had raised TAT concentrations. Median TAT concentrations in the presence of DIC (27 micrograms/l) were significantly higher than in its absence (8 micrograms/l). Sensitivity, specificity, and positive and negative predictive values of the assay were 97.3%, 28.3%, 76.3%, and 81.3%, respectively, at a cut off of 4 micrograms/l. Excess thrombin production occurs in the majority of critically ill children. The TAT assay is potentially useful in the diagnosis of DIC in children.     

Predictors of outcome following traumatic brain injury in young children

The relationship between clinical and neuroimaging variables and multiple outcome measures was examined in a longitudinal, prospective study of 60 children less than 6 years of age who sustained either inflicted or noninflicted traumatic brain injury. Hierarchical multiple regression indicated that the modified Glasgow Coma Scale score, the duration of impaired consciousness and the number of intracranial lesions visualized on CT/MRI accounted for a significant amount of the variance in the Glasgow Outcome Scale (GOS), cognitive and motor scores at baseline, 3- and 12-month evaluations. Inflicted brain injury adversely affected both GOS and cognitive outcomes. Pupillary abnormalities were associated with poorer motor outcome. Neither age at injury nor the Injury Severity Score accounted for significant variability in outcomes.     

儿童颅脑外伤的诊治原则

创伤性颅脑损伤严重危害人类的生活和健康,易引起残疾和死亡。特别是小儿颅脑损伤,临床表现复杂,病情变化快,早期各种并发症发生率高,但处理及时得当及病情稳定后有效的康复治疗使恢复空间大。     

Proton spectroscopy detected myoinositol in children with traumatic brain injury

Previous studies have shown that proton magnetic resonance spectroscopy (MRS) is useful in predicting neurologic prognosis in children with traumatic brain injury (TBI). Reductions in N-acetyl derived metabolites and presence of lactate have been predictive of poor outcomes. We examined another spectroscopy metabolite, myoinositol (mI), to determine whether it is altered after TBI. Found primarily in astrocytes, mI functions as an osmolyte and is involved in hormone response pathways and protein-kinase C activation. Myoinositol is elevated in the newborn brain and is increased in a variety of diseases. We studied 38 children (mean age 11 y; range 1.6-17 y) with TBI using quantitative short echo time occipital gray and parietal white matter proton MRS at a mean of 7 d (range 1-17 d) after injury. We found that occipital gray matter mI levels were increased in children with TBI (4.30 +/- 0.73) compared with controls (3.53 +/- 0.48; p = 0.003). We also found that patients with poor outcomes 6-12 mo after injury had higher mI levels (4.78 +/- 0.68) than patients with good outcomes (4.15 +/- 0.69; p < 0.05). Myoinositol is elevated after pediatric TBI and is associated with a poor neurologic outcome. The reasons for its elevation remain unclear but may be due to astrogliosis or to a disturbance in osmotic function.     

Functional memory skills following traumatic brain injury in young children

Traumatic brain injury (TBI) may have a profound impact on a child's ongoing development. Various risk factors have been found to predict outcome, but considerable variability remains unexplained. This study used a prospective, longitudinal design to examine recovery of memory function following TBI within the pre-school period. Forty-four children with TBI were divided according to injury severity (mild, moderate, severe), and compared to age and SES matched healthy controls (n = 26). Children were evaluated acutely and at 12 months post-injury using the Rivermead Behavioural Memory Test for Children. Results failed to show a clear dose-response relationship between injury severity and memory function during the acute phase of recovery. However, this relationship developed over time, with greater memory impairments evident for children with more severe TBI by 12 months post-injury. Children with mild TBI exhibited few memory problems.     

去骨瓣减压术在儿童重型颅脑损伤中的应用及研究进展

儿童颅脑损伤是引起儿童创伤死亡和致残的首位危险因素.多数颅脑损伤为轻中度损伤,预后相对良好.重型颅脑损伤(severe TBI,sTBI)是指心肺复苏后格拉斯哥昏迷指数(glasgow coma scale,GCS)评分≤8分的颅脑外伤,常常会导致患儿死亡或残疾.外科常采用去颅瓣减压术(decompressive craniectomy,DC)治疗TBI患儿,通过去除部分颅骨,使脑实质不再受限于骨腔,通过增加脑容积来降低颅内压(intracranial pressure,ICP),从而改善脑灌注压力(cerebral perfusion pressure,CPP),并降低发生大脑中线移位、脑干压缩和脑疝的概率:然而DC通常不是首选策略而是作为辅助治疗手段用于临床.本文就DC的优缺点及其在儿童重症颅脑外伤中的应用和研究进展进行探讨.     

Analysis of perpetrator admissions to inflicted traumatic brain injury in children

BACKGROUND: Scientific and courtroom debate exists regarding the timing of onset of symptoms and the mechanism of injury in infants and children with inflicted traumatic brain injury (ITBI). OBJECTIVES: To determine the time interval between ITBI and the onset of symptoms and to explore the mechanism of ITBI. DESIGN, SETTING, AND PATIENTS: Retrospective review of all cases of pediatric ITBI admitted between January 1, 1981, and July 31, 2001, to a large academic medical center and cases admitted to 2 additional academic institutions between January 1, 1996, and August 31, 2000, and January 1, 2001, and July 31, 2001, comparing 81 cases of ITBI in which perpetrators admitted to abuse with 90 cases in which no abuse admission was made. The patients with perpetrator admissions to ITBI consisted of 53 boys (65%) and 28 girls (35%). Their ages ranged from 2 weeks to 52 months. MAIN OUTCOME MEASURES: Characteristics associated with perpetrator admissions to ITBI in children. RESULTS: Shaking was the most common mechanism of injury among all cases with perpetrator admissions: 55 (68%) of the 81 perpetrators admitted to shaking the children. Impact was not described in 44 (54%) of the 81 cases. In cases in which only impact was described, 60% (12/20) of the children showed skull or scalp injury, compared with 12% (4/32) with skull or scalp injury in the shake only group. In 52 (91%) of 57 cases in which the time to the onset of symptoms was described, symptoms appeared immediately after the abuse. In 5 cases (9%), the timing of symptoms was less clear, but they occurred within 24 hours. None of the children were described as behaving normally after the event. CONCLUSIONS: The symptoms of inflicted head injury in children are immediate. Most perpetrators admitted to shaking without impact. These data, combined with the relative lack of skull and scalp injury, suggest that shaking alone can produce the symptoms seen in children with ITBI.     

亚低温在儿童重型外伤性脑损伤治疗中的初步应用评价

目的 探讨亚低温对儿童外伤性脑损伤(traumatic brain injury,TBI)的脑保护作用,并评价其临床安全性.方法 将22例重症TBI患儿随机分为亚低温治疗组(颅温(34.5±0.2)℃,持续72h;n=12)和常温对照组(不进行降温治疗;n=10).检测脑脊液中特异性烯醇化酶(NSE)、S-100蛋白(S-100)、磷酸肌酸激酶脑型同工酶(CK-BB)的变化,监测颅内压及生命体征、酸碱平衡、血电解质水平.结果 常温对照组伤后48 h颅内压达高峰,平均为(26.2±8.7)mm Hg,亚低温治疗组颅内压均维持在较低水平,各时点指标较常温对照组均明显降低(P<0.01);亚低温治疗组脑脊液S-100、CK-BB测定值明显低于常温对照组各时点水平(P<0.05、P<0.001);两组生命体征稳定,血酸碱平衡,血电解质正常,亚低温组心率较常温组降低(P<0.05).结论 亚低温对儿童严重TBI具有较好的脑保护作用.颅温34.5℃左右,持续72 h在临床上是安全的.     

Cerebral autoregulation in pediatric traumatic brain injury.

OBJECTIVE: The aims of this study were to document the incidence of impaired cerebral autoregulation in children with traumatic brain injury using transcranial Doppler ultrasonography and to examine the relationship between autoregulatory capacity and outcome in children following traumatic brain injury. DESIGN: Prospective cohort study. SETTING: Harborview Medical Center (level I pediatric trauma center) in Washington state. PATIENTS: Thirty-six children <15 yrs old with traumatic brain injury: Glasgow Coma Scale score <9 (n = 12, group 1), Glasgow Coma Scale score 9-12 (n = 12, group 2), and Glasgow Coma Scale score 13-15 (n = 12, group 3). INTERVENTIONS: Cerebral autoregulation testing was conducted during extracranial surgery. Mean middle cerebral artery flow velocities were measured using transcranial Doppler as mean arterial pressure was increased to whichever variable was greater: 20% above baseline or a set value (80 mm Hg for <9 yrs and 90 mm Hg for 9-14 yrs). Autoregulatory capacity was quantified by the Autoregulatory Index. Autoregulatory Index <0.4 was considered impaired cerebral autoregulation. Discharge outcome using the Glasgow Outcome Scale score was considered good if the Glasgow Outcome Scale score was > or =4. MEASUREMENTS AND MAIN RESULTS: Twenty-four (67%) of 36 children had an Autoregulatory Index > or =0.4. The incidence of impaired cerebral autoregulation was 42% (five of 12) in group 1, 42% (five of 12) in group 2, and 17% (two of 12) in group 3. Ten (42%) of the 24 children with intact cerebral autoregulation had a good outcome compared with only one of 12 (8%) children with impaired cerebral autoregulation (p =.04). Six of 12 (50%) children with impaired cerebral autoregulation had hyperemia compared with one of 24 (4%) children with intact cerebral autoregulation (p <.01). Hyperemia was associated with poor outcome (p =.01). CONCLUSIONS: The incidence of impaired cerebral autoregulation was greatest following moderate to severe traumatic brain injury. Impaired cerebral autoregulation was associated with poor outcome. Hyperemia was associated with impaired cerebral autoregulation and poor outcome.