Peut-on prédire l’aggravation neurologique des patients traumatisés crâniens mineurs et modérés par le dosage sanguin de la protéine S-100β ?

Introduction

Patients with moderate traumatic brain injury (TBI) (Glasgow Coma Scale, GCS, 9–13) or minor TBI (GCS 14–15) are at risk for subsequent neurological deterioration. Serum protein S-100 is believed to reflect brain damage following TBI. In patients with normal or minor CT scan abnormalities on admission, we tested whether the determination of serum protein S-100 beta could predict secondary neurological deterioration.

Methods

Sixty-seven patients with moderate or minor TBI were prospectively studied. Serum samples were collected on admission within 12 hours postinjury to measure serum protein S-100 levels. Neurological outcome was assessed up to seven days after trauma. Secondary neurological deterioration was defined as two points or more decrease from the initial GCS, or any treatment for neurological deterioration.

Results

Nine patients had a secondary neurological deterioration after trauma. No differences in serum levels of protein S-100 were found between these patients and those without neurological aggravation (n = 58 patients): 0.93 μg/l (0.14–4.85) vs 0.39 μg/l (0.04–6.40), respectively. The proportion of patients with abnormal levels of serum protein S-100 at admission according to two admitted cut-off levels (> 0.1 and > 0.5 μg/l) was comparable between the two groups of patients. Elevated serum levels of protein S-100 were found in patients with Injury Severity Score (ISS) of more than 16 (n = 23 patients): 1.26 μg/l (0.14–6.40) vs 0.22 μg/l (0.04–6.20) in patients with ISS less than 16 (n = 44 patients).

Discussion

The dosage of serum protein S-100 on admission failed to predict patients at risk for neurological deterioration after minor or moderate TBI. Extracranial injuries can increase serum protein S-100 levels, then limiting the usefulness of this dosage in this clinical setting.     

Determinants of wait time for infant inguinal hernia repair in a Canadian children’s hospital

Background

Longer wait time for infant inguinal hernia (IH) repair is associated with higher complication rates. We wished to determine if socioeconomic and demographic factors influence wait times for IH repair.

Methods

Children < 2 years old with IH at a Canadian children’s hospital were retrospectively reviewed. Days from diagnosis to surgical consultation (W1) and from consultation to repair (W2) were collected along with demographic, medical, and socioeconomic data. Linear regression analysis was performed.

Results

A total of 131 patients were appropriate for analysis (82.4% male). Median distance to hospital was 27.5 km (IQR = 10.5–50.4) and median income was $34,477 (IQR = 30,127–41,986). Median W1, W2, and Wtotal (W1 + W2) were 24 (IQR = 8–48), 43 (IQR = 21–69) and 79 (IQR = 38–112) days, respectively. Wait times were shorter in infants who were male (p = 0.044), symptomatic (p < 0.001), diagnosed in the ED (p < 0.001), or had an incarcerated hernia (p = 0.006). They were longer for premature infants (p = 0.009) and those with significant comorbidities (p = 0.018). Neither income (p = 0.328) nor distance from hospital (p = 0.292) was associated with longer wait times.

Conclusion

Wait times for IH repair were appropriately influenced by medical risk factors. Income and distance to hospital did not appear to influence wait times. A population-based study is needed to determine if these findings reflect a general trend within the Canadian health care system.     

Head injury and unclear mechanism of injury: Initial hematocrit less than 30 is predictive of abusive head trauma in young children

Purpose

Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT.

Methods

A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002–2011.

Results

A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P < .0001), as was a platelet count of greater than 400,000 (P < .0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P < .05).

Conclusions

In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years.     

Physician-based emergency medical service deployment characteristics in severe traumatic brain injury: A Dutch multicenter study

Introduction

Prehospital guidelines advise advanced life support in all patients with severe traumatic brain injury (TBI). In the Netherlands, it is recommended that prehospital advanced life support is particularly provided by a physician-based helicopter emergency medical service (P-HEMS) in addition to paramedic care (EMS). Previous studies have however shown that a substantial part of severe TBI patients is exclusively treated by an EMS team. In order to better understand this phenomenon, we evaluated P-HEMS deployment characteristics in severe TBI in a multicenter setting.

Methods

The database included patient demographics, prehospital and injury severity parameters and determinants of EMS or EMS/P-HEMS dispatch in 334 patients with severe TBI admitted to level 1 trauma centres in the Netherlands.

Results

P-HEMS was deployed in 62% of patients with severe TBI. Patients treated by the P-HEMS had a higher injury severity score (29 (20–38)) vs. (25 (16–30); P < 0.001), more frequently required blood product transfusions (41% vs. 29%; P = 0.03) and recurrently suffered from TBI with extracranial injuries (33% vs. 6%; P < 0.001) than patients solely treated by an EMS. The prehospital endotracheal intubation rate was higher in the P-HEMS group in isolated TBI (93% vs. 19%; P < 0.001) or TBI with extracranial injuries (96% vs. 43%; P < 0.001) compared to the EMS group. In the EMS group, more patients were secondary referred to a level 1 trauma centre (32% vs. 4%; P < 0.001 vs. P-HEMS). Despite higher injury severity levels in P-HEMS patients, 6-month mortality rates were similar among groups, irrespective of the presence of extracranial injuries in addition to TBI. Deployment of P-HEMS estimated 52% and 72% (P < 0.001) in urban and rural regions, respectively, with comparable endotracheal intubation rates among regions.

Conclusions

This study shows that a physician-based HEMS was more frequently deployed in patients with severe TBI in the presence of extracranial injuries, and in rural trauma regions. Treatment of severe TBI patients by a paramedic EMS only was associated with a higher incidence of secondary referrals to a level I trauma centre. Our data support adjustment of local prehospital guidelines for patients with severe TBI to the geographical context.     

Maternal medical and behavioral risk factors for congenital diaphragmatic hernia

Purpose

Maternal factors contributing to the etiology of congenital diaphragmatic hernia (CDH) remain unclear. We hypothesized that specific maternal medical conditions (pregestational diabetes, hypertension), and behaviors (alcohol, tobacco) would be associated with CDH.

Methods

We conducted a population-based case–control study using Washington State birth certificates linked to hospital discharge records (1987–2009). We identified all infants with CDH (n = 492). Controls were randomly selected among non-CDH infants. Maternal data were extracted from the birth record. Logistic regression was used to adjust for covariates.

Results

Cases and controls were generally similar regarding demographics, although CDH infants were more likely to be male than controls (58.5% vs. 52.5%). Isolated and complex (multiple-anomaly) CDH had similar characteristics. Each of the exposures of interest was more common among case mothers than among control mothers. In univariate analysis, alcohol use, hypertension, and pregestational diabetes were each significantly associated with the outcome. After multivariate adjustment, only alcohol use (OR = 3.65, p = 0.01) and pregestational diabetes (OR = 12.53, p = 0.003) maintained significance. Results were similar for both isolated and complex CDH.

Conclusions

Maternal pregestational diabetes and alcohol use are significantly associated with occurrence of CDH in infants. These are important modifiable risk factors to consider with regard to efforts seeking to impact the incidence of CDH.     

Outcome of CDH infants following fetoscopic tracheal occlusion — influence of premature delivery

Purpose

To evaluate the mortality and morbidity of infants with congenital diaphragmatic hernia who had undergone fetal endoscopic tracheal occlusion (FETO) and whether this was influenced by premature birth.

Methods

The gestational age at delivery, lung–head ratio (LHR) pre and post FETO, neonatal outcomes, and respiratory, gastro-intestinal, neurological, surgical, and musculoskeletal problems at follow up of consecutive infants who had undergone FETO were determined. Elective reversal of FETO was planned at 34 weeks of gestation.

Results

The survival rate of the 61 FETO infants was 48%, with 84% delivered prematurely. Thirty-one delivered < 35 weeks of gestation. Their survival rate was 18%. Twenty-three of 24 infants who had emergency balloon removal were born < 35 weeks of gestation. Survival was related to gestational age at delivery (OR 0.55, 95% CI 0.420, 0.77, p < 0.001) and the duration of FETO (OR 0.73, 95% CI 0.59, 0.91, p < 0.005). Infants born prior to 35 weeks of gestation compared to those born at ≥ 35 weeks required a longer duration of ventilation (median 45 days versus 12 days, p < 0.001), and a greater proportion had surgery for gastro-oesophageal reflux (50% versus 9%, p = 0.011).

Conclusion

These results emphasize the need to reduce premature delivery following FETO.     

Hypernatremia severity and the risk of death after traumatic brain injury

Purpose

To investigate the relationship between severity of hypernatremia and the risk of death for patients with traumatic brain injury (TBI) who have been admitted to the neurosurgical intensive care unit (NICU).

Methods

A total of 1044 patients with TBI were admitted to our NICU from January 2005 to January 2010. Of these patients, 881 were included in this study. Based on blood serum sodium level in the NICU the 881 patients were divided into four groups: 614 had normal serum sodium (Na < 150 mmol/L), 34 had mild hypernatremia (Na 150–<155 mmol/L), 66 had moderate hypernatremia (Na 155–160 mmol/L) and 167 had severe hypernatremia (Na ≥ 160 mmol/L).

Results

The mortality rates for the mild, moderate, and severe hypernatremia groups were 20.6%, 42.4%, and 86.8%, respectively; the mortality rate for the normal group was 2.0%. In multivariable analysis, mild, moderate, and severe hypernatremia were independent risk factors for mortality; compared with the normal group the odds ratios of mild, moderate, and severe hypernatremia were 9.50, 4.34, and 29.35, respectively.

Conclusions

Severe hypernatremia is an independent risk factor with extremely high odds ratio for death in patients with TBI who are admitted to the NICU.     

Cervical spine computed tomography utilization in pediatric trauma patients

Background

Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs).

Methods

Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression.

Results

5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p < 0.05) and more frequent ICU admissions (44.3% vs. 26.1% p < 0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI = 8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI = 25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT.

Conclusions

Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.     

Pepsin levels and oxidative stress markers in exhaled breath condensate of patients with gastroesophageal reflux disease

Aim

To evaluate the pepsin and oxidative stress markers in exhaled breath condensate (EBC) in patients with gastroesophageal reflux disease (GERD).

Patients and Method

Patients with a presumptive diagnosis of GERD with recurrent respiratory and gastrointestinal problems aged between 2 and 14 years were included in the study. All patients underwent pH monitoring. Patients with a reflux index (RI) ≥ 4 were assessed as the reflux group, and those with an RO < 4 were assessed as the non-reflux group. Pepsin levels and oxidative stress markers [NO metabolites (NOX) and total sulphydrile (TSH) levels] were measured in the EBC.

Results

There were 24 patients in the reflux group [RI 17.6 (6.6–46.4)] [median, interquartile range] and 23 in the non-reflux group [RI 0.8 (0.5–1.9) (p < 0.001). Pepsin levels in the EBC were below the level of detection. The median levels of NOx in the EBC of children with reflux [13.7 μmol/L (7.3–24.5)] were lower in than non-reflux group [21.0 μmol/L (14.0–25.2)] (p = 0.034). There was a negative correlation between reflux index and NOX levels in EBC (rs: − 0.331, p = 0.023). In contrast, there was no difference in TSH levels between the reflux and non-reflux groups [37.4 μmol/L (30.2–44.6) vs 40.1 μmol/L (37.4–44.9), respectively, (p > 0.05)].

Conclusion

Decreased levels of NOX in patients with GER disease suggest increased oxidative stress in airways of these patients.     

Gastric emptying in children with gastroesophageal reflux and in healthy children

Purpose

The aim of this report is to examine whether children with gastroesophageal reflux (GER) have delayed gastric emptying compared to healthy children.

Methods

All patients had GER verified by 24-hour pH monitoring. Gastric emptying of cow’s milk was examined by radionuclide scintigraphy in 51 patients with GER and in 24 controls. Gastric emptying rate was expressed as exponential half time (T_1/2).

Results

Median age was 4.4 years [range 0.1–15.4] in patients and 6.1 years [range 2.5–10.0] in controls (p = .10). A wide range of gastric emptying rates was observed both in GER patients [range 16–121] and controls [range 29–94]. One GER patient (2%) had slower gastric emptying (T_1/2 = 121 min) than the healthy child with the longest T_1/2 (94 min). Mean T_1/2 was 49 minutes (SD 20.1) and 46 minutes (SD 14.2) in GER patients and controls, respectively (p = .51).

Conclusions

Gastric emptying rate of milk was not significantly different between children with GER and healthy children. A wide range of gastric emptying rates was observed in both groups.     

Mechanisms of motor vehicle crashes related to burns—An analysis of the German In Depth Accident Study (GIDAS) database

Background

Patients of motor vehicle crashes (MVCs) suffering burns are challenging for the rescue team and the admitting hospital. These patients often face worse outcomes than crash patients with trauma only. Our analysis of the German In-depth Accident Study (GIDAS) database researches the detailed crash mechanisms to identify potential prevention measures.

Methods

We analyzed the 2011 GIDAS database comprising 14,072 MVC patients and compared individuals with (Burns) and without (NoBurns) burns. Only complete data sets were included. Patients with burns obviously resulting of air bag deployment only were not included in the Burns group. Data acquisition by an on call team of medical and technical researchers starts at the crash scene immediately after the crash and comprises technical data as well as medical information until discharge from the hospital. Statistical analysis was done by Mann–Whitney-U-test. Level of significance was p < 0.05.

Results

14,072 MVC patients with complete data sets were included in the analysis. 99 individuals suffered burns (0.7%; group “Burns”). Demographic data and injury severity showed no statistical significant difference between the two groups of Burns and NoBurns. Injury severity was measured using the Injury Severity Score (ISS). Direct frontal impact (Burns: 48.5% vs. NoBurns: 33%; p < 0.05) and high-energy impacts as represented by delta-v (m/s) (Burns: 33.5 ± 21.4 vs. NoBurns: 25.2 ± 15.9; p < 0.05) were significantly different between groups as was mortality (Burns: 12.5% vs. NoBurns: 2.1%; p < 0.05). Type of patients’ motor vehicles and type of crash opponent showed no differences.

Conclusions

Our results show, that frontal and high-energy impacts are associated with a frequency of burns. This may serve automobile construction companies to improve the burn safety to prevent flames spreading from the motor compartment to the passenger compartment. Communities may impose speed limits in local crash hot spots.     

Interleukin-8 predicts 60-day mortality in premature infants with necrotizing enterocolitis

Objective

The purpose of this study was to evaluate the predictiveness of circulating interleukin (IL)-8 for 60-day mortality in premature infants with necrotizing enterocolitis (NEC).

Background

NEC affects up to 5% of premature infants and remains a leading cause of mortality among neonates.

Methods

A total of 113 infants with surgically (n = 50) or medically (n = 63) treated NEC were retrospectively analyzed. Laboratory parameters including serum IL-8 were assessed at the diagnosis of NEC and during the preoperative workup.

Results

The 60-day mortality was 19% (22/113), 10% (6/63) in medical and 33% (16/50) in surgical NEC. IL-8 levels significantly correlated with 60-day mortality (odds ratio: 1.38; CI 1.14–1.67; p = 0.001). Median IL-8 levels at diagnosis were significantly higher in neonates who were later treated surgically (median = 2625 pg/ml; range: 27–7500) compared with those treated medically (median = 156 pg/ml; range: 5–7500; p < 0.001). The AUC to discriminate between medical and surgical NEC was 0.82 (CI, 0.74–0.90), and an exploratory IL-8 cutoff point could be established at 1783 pg/ml (sensitivity of 90.5%; specificity of 59.2%).

Conclusions

Our findings that serum IL-8 (i) correlates directly with 60-day mortality and (ii) differs significantly between medically and surgically treated infants may change the process of therapeutic decision making in NEC.     

Trauma induced hypercoagulablity in pediatric patients

Purpose

Coagulation changes in pediatric trauma patients are not well defined. To fill this gap, we tested the hypothesis that trauma evokes a hypercoagulable response.

Methods

A prospective observational study was conducted in hospitalized patients (age 8 months to 14 years) admitted for trauma or elective surgery. Informed consent was obtained from the parents and informed assent was obtained in patients 7 years of age or older. Coagulation changes were evaluated on fresh whole blood using thromboelastography (TEG) and on stored plasma using assays for special clotting factors.

Results

Forty three patients (22 trauma, median injury severity score = 9; and 21 uninjured controls) were evaluated. For trauma vs control, prothrombin time (PT) was higher by about 10% (p < 0.001), but activated partial thromboplastin time was not altered. TEG clotting time (R;p = 0.005) and fibrin cross-linking were markedly accelerated (K time, alpha angle; p < 0.001) relative to the control patients. d-Dimer, Prothrombin Fragment 1 + 2, and Plasminogen Activator Inhibitor-1 were all elevated, whereas Protein S activity was reduced (all p < 0.01). Importantly, a large fraction of TEG values and clotting factor assays in the pediatric control group were outside the published reference ranges for adults.

Conclusion

A hypercoagulable state is associated with minor trauma in children. More work is needed to determine the functional significance of these changes and to establish normal pediatric reference ranges.     

Multicenter retrospective comparative study of laparoscopically assisted and conventional anorectoplasty for male infants with rectoprostatic urethral fistula

Background

Laparoscopically assisted anorectoplasty (LAARP) was expected to achieve better fecal continence than conventional procedures. However, the issue of which approach is better remains controversial. We compared outcomes between the conventional procedure and LAARP in male infants with rectoprostatic urethral fistula.

Methods

Institutes belonging to the Japanese Study Group of Anorectal Anomalies (JSGA) were invited to participate. Subjects were male infants with rectoprostatic urethral fistula treated by the conventional approach (abdominoperineal pull-through and PSARP) or LAARP between 2000 and 2006. Medical charts and operative records were reviewed retrospectively.

Results

Eighty-one patients (conventional: 36, LAARP: 45) were enrolled from 15 centers. In both groups, the mean Kelly score was 5. The total score of the scoring system was newly developed by the Japanese Study Group of Anorectal Anomalies. Follow-up Project (5–15 points) was 10.7 and 12.1 in the conventional group and the LAARP group, respectively (p = 0.07). The incidence of failed rectoanal anastomosis, mucosal prolapse, and anal stenosis was comparable in both groups. Posterior urethral diverticula were detected on cystourethrograms in 7% and 11% (p = 1.0) and on MRI in 0% and 34% (p = 0.02) of the conventional and the LAARP groups, respectively. Overall, 94% of diverticula were asymptomatic.

Conclusions

Fecal continence and complication rates after LAARP were comparable to those observed after the conventional method. Posterior urethral diverticula were detected more frequently after LAARP.     

The association of type of surgical closure on length of stay among infants with gastroschisis born ≥ 34 weeks’ gestation

Background/Purpose

The optimal surgical approach in infants with gastroschisis (GS) is unknown. The purpose of this study was to estimate the association between staged closure and length of stay (LOS) in infants with GS.

Design/Methods

We used the Children's Hospital Neonatal Database to identify surviving infants with GS born ≥ 34 weeks' gestation referred to participating NICUs. Infants with complex GS, bowel atresia, or referred after 2 days of age were excluded. The primary outcome was LOS; multivariable linear regression was used to quantify the relationship between staged closure and LOS.

Results

Among 442 eligible infants, staged closure occurred in 68.1% and was associated with an increased median LOS relative to odds ration (OR):primary closure (37 vs. 28 days, p < 0.001). This association persisted in the multivariable equation (β = 1.35, 95% CI: 1.21, 1.52, p < 0.001) after adjusting for the presence of necrotizing enterocolitis, short bowel syndrome, and central-line associated bloodstream infections.

Conclusions

In this large, multicenter cohort of infants with GS, staged closure was independently associated with increased LOS. These data can be used to enhance antenatal and pre-operative counseling and also suggest that some infants who receive staged closure may benefit from primary repair.     

Impact de la mise en place d’un réseau de soins en traumatologie sur la mortalité des patients traumatisés graves du bassin

Aim

To evaluate the impact of a regional trauma network on intra-hospital mortality rates of patients admitted with severe pelvic trauma.

Study

Retrospective observational study.

Patients

Sixty-five trauma patients with serious pelvic fracture (pelvic abbreviated injury scale [AIS] score of 3 or more).

Methods

Demographic, physiologic and biological parameters were recorded. Observed mortality rates were compared to predicted mortality according to the Trauma Revised Injury Severity Score methodology adjusted by a case mix variation model.

Results

Twenty-nine patients were admitted in a level I trauma centre (reference centre) and 36 in level II trauma centres (centres with interventional radiology facility and/or neurosurgery). Patients from the level I trauma centre were more severely injured than those who were admitted at the level II trauma centres (Injury Severity Score [ISS]: 30 [13–75] vs 22 [9–59]; P < 0.01). Time from trauma to hospital admission was also longer in level I trauma centre (115 [50–290] min vs 90 [28–240] min, P < 0.01). Observed mortality rates (14%; 95% confidence interval, 95% CI, [1–26%]) were lower than the predicted mortality (29%; 95% CI [13–44%]) in the level I trauma centre. No difference in mortality rates was found in the level II trauma centres.

Conclusion

The regional trauma network could screen the most severely injured patients with pelvic trauma to admit them at a level I trauma centre. The observed mortality of these patients was lower than the predicted mortality despite increased time from trauma to admission.     

Prognostic value of abdominal sonography in necrotizing enterocolitis of premature infants born before 33 weeks gestational age

Objective

The purpose of this study was to assess the prognostic value of abdominal sonography in necrotizing enterocolitis (NEC) in preterm infants with a gestational age less than 33 weeks of gestation, using surgery and/or death as the primary outcome and stenosis as the secondary outcome.

Methods

A retrospective study of 95 premature infants (mean gestational age: 28.6 weeks), presenting with NEC between January 2009 and November 2011 and who underwent plain abdominal radiography and sonography, was performed. In uni- and multivariate analyses, radiographic and sonographic findings were correlated with complications (‘surgery and/or death’ and ‘stenosis’).

Results

Sonographic findings of free intraperitoneal air (odd ratio [OR] = 8.0; IC, 1.4–44.2), free abdominal fluid (OR 3.5; IC 1.3–9.4), portal venous gas (OR 3.9; IC, 1.2–12.9), and bowel wall thickening (OR 2.8; IC,1.1–7.2) were significantly associated with surgery and/or death. Intramural gas was significantly correlated (OR = 11.8; IC, 1.5–95.8) with intestinal stenosis following NEC. None of the radiographic findings were associated with complications.

Conclusion

Abdominal sonography is a reliable tool for the prognostic assessment of NEC in preterm infants.     

Base deficit correlates with mortality in pediatric abusive head trauma

Background/purpose

Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome.

Methods

We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05.

Results

Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05).

Conclusions

BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT.     

The outcome of critically ill neonates undergoing laparotomy for necrotising enterocolitis in the neonatal intensive care unit: a 10-year review

Purpose

To evaluate outcomes in critically ill neonates with necrotising enterocolitis (NEC) undergoing a laparotomy in the neonatal intensive care unit (NICU).

Methods

This is a retrospective review of neonates diagnosed with NEC who underwent a laparotomy on NICU between 2001 and 2011. Demographic, diagnostic, operative and outcome data were analysed. Nonparametric comparison was used. Data are reported as median (range).

Results

221 infants with NEC were referred for surgical evaluation; 182 (82%) underwent surgery; 15 (8%) required a laparotomy on NICU. Five had NEC totalis, 4 multifocal disease and 6 focal disease. Five had an open and close laparotomy, 8 stoma with/without bowel resection and 2 bowel resection and primary anastomosis. Ten (67%) died at a median of 6.5-hours (2–72) postoperatively; 2 died at 72 and 264-days. The 30-day mortality rate was higher (p = 0.01) among infants undergoing a laparotomy on NICU (10/15; 67%) than in theatre (54/167; 32%). There was no significant difference in mean Paediatric Index of Mortality 2 Scores between survivors and nonsurvivors (p = 0.55). Three (20%) infants remain alive with no or minimal disability at 1.4 (0.5–7.5) years.

Conclusion

Laparotomy for NEC on NICU is a treatment option for neonates who are too unstable to transfer to theatre. However, with 67% dying within 6.5-hours and a further 13% after months in hospital, we must consider whether surgery is always in their best interests. Development of a prediction model to help distinguish those at highest risk of long-term morbidity and mortality could help with decision making in this difficult situation.     

The effect of admission spontaneous hypothermia on patients with severe traumatic brain injury

Introduction

Recent information has emerged regarding the harmful effects of spontaneous hypothermia at time of admission in trauma patients. However the volume of evidence regarding the role of spontaneous hypothermia in TBI patients is inadequate.

Methods

We performed secondary data analysis of 10 years of the Pennsylvania trauma outcome study (PTOS) database. Unadjusted comparisons of the association of admission spontaneous hypothermia with mortality were performed. In addition, full assessment of the association of hypothermia with mortality was conducted using multivariable logistic regressions reporting the odds ratios (OR) with the 95% confidence intervals (CI) and P-values.

Results

There were 11,033 patients identified from the PTOS with severe TBI. There were 4839 deaths (43.9%). The proportion of deaths in hypothermic patients was higher than the proportion of deaths in normothermic patients (53.9% vs. 37.4% respectively; P value < 0.001). In a multivariable logistic regression model adjusted for demographics, injury characteristics, and information at admission to the trauma centre, the odds of death among patients with hypothermia were 1.70 times the odds of death among patients with normothermia (OR 1.70, 95% CI 1.50–1.93), indicating that the probability of death was significantly higher when patients arrived hypothermic at the trauma centre.

Conclusion

The presence of spontaneous hypothermia at hospital admission is associated with a significant increase in the risk of mortality in patients with severe TBI. The benefit of maintaining normothermia in severe TBI patients, the impact of prolonged re-warming in patients with established hypothermia and the introduction of prophylactic measures to complications of hypothermia are key points that require further investigation.