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Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging.

ABSTRACT: OBJECTIVES:To describe the disposition of infants and young children with isolated mild traumatic brain injury and neuroimaging findings evaluated at a level 1 pediatric trauma center, and identify factors associated with their need for ICU admission. DESIGN:Retrospective cohort. SETTING:Single center. PATIENTS:Children less than or equal to 4 years old with mild traumatic brain injury (Glasgow Coma Scale 13-15) and neuroimaging findings evaluated between January 1, 2013, and December 31, 2015. Polytrauma victims and patients requiring intubation or vasoactive infusions preadmission were excluded. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Two-hundred ten children (median age/weight/Glasgow Coma Scale: 6 mo/7.5?kg/15) met inclusion criteria. Most neuroimaging showed skull fractures with extra-axial hemorrhage/no midline shift (30%), nondisplaced skull fractures (28%), and intracranial hemorrhage without fractures/midline shift (19%). Trauma bay disposition included ICU (48%), ward (38%), intermediate care unit and home (7% each). Overall, 1% required intubation, 4.3% seizure management, and 4.3% neurosurgical procedures; 15% were diagnosed with nonaccidental trauma. None of the ward/intermediate care unit patients were transferred to ICU. Median ICU/hospital length of stay was 2 days. Most patients (99%) were discharged home without neurologic deficits. The ICU subgroup included all patients with midline shift, 62% patients with intracranial hemorrhage, and 20% patients with skull fractures. Across these imaging subtypes, the only clinical predictor of ICU admission was trauma bay Glasgow Coma Scale less than 15 (p = 0.018 for intracranial hemorrhage; p < 0.001 for skull fractures). A minority of ICU patients (18/100) required neurocritical care and/or neurosurgical interventions; risk factors included neurologic deficit, loss of consciousness/seizures, and extra-axial hemorrhage (especially epidural hematoma). CONCLUSIONS:Nearly half of our cohort was briefly monitored in the ICU (with disposition mostly explained by trauma bay imaging, rather than clinical findings); however, less than 10% required ICU-specific interventions. Although ICU could be used for close neuromonitoring to prevent further neurologic injury, additional research should explore if less conservative approaches may preserve patient safety while optimizing healthcare resource utilization.

SUBMITTER: Noje C

PROVIDER: S-EPMC7050196 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging.

Noje Corina C Jackson Eric M EM Nasr Isam W IW Costabile Philomena M PM Cerullo Marcelo M Hoops Katherine K Rasmussen Lindsey L Henderson Eric E Ziegfeld Susan S Puett Lisa L Robertson Courtney L CL

Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies 20191101 11

<h4>Objectives</h4>To describe the disposition of infants and young children with isolated mild traumatic brain injury and neuroimaging findings evaluated at a level 1 pediatric trauma center, and identify factors associated with their need for ICU admission.<h4>Design</h4>Retrospective cohort.<h4>Setting</h4>Single center.<h4>Patients</h4>Children less than or equal to 4 years old with mild traumatic brain injury (Glasgow Coma Scale 13-15) and neuroimaging findings evaluated between January 1, ...[more]

PMID: 31232854

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Project description:To examine the use of intracranial pressure monitors and treatment for elevated intracranial pressure in children 24 months old or younger with traumatic brain injury in North Carolina between April 2009 and March 2012 and compare this with a similar cohort recruited 2000-2001.Prospective, observational cohort study.Twelve PICUs in North Carolina.All children 24 months old or younger with traumatic brain injury, admitted to an included PICU.None.The use of intracranial pressure monitors and treatments for elevated intracranial pressure were evaluated in 238 children with traumatic brain injury. Intracranial pressure monitoring (risk ratio, 3.7; 95% CI, 1.5-9.3) and intracranial pressure therapies were more common in children with Glasgow Coma Scale less than or equal to 8 compared with Glasgow Coma Scale greater than 8. However, only 17% of children with Glasgow Coma Scale less than or equal to 8 received a monitoring device. Treatments for elevated intracranial pressure were more common in children with monitors; yet, some children without monitors received therapies traditionally used to lower intracranial pressure. Unadjusted predictors of monitoring were Glasgow Coma Scale less than or equal to 8, receipt of cardiopulmonary resuscitation, nonwhite race. Logistic regression showed no strong predictors of intracranial pressure monitor use. Compared with the 2000 cohort, children in the 2010 cohort with Glasgow Coma Scale less than or equal to 8 were less likely to receive monitoring (risk ratio, 0.5; 95% CI, 0.3-1.0), although the estimate was not precise, or intracranial pressure management therapies.Children in the 2010 cohort with a Glasgow Coma Scale less than or equal to 8 were less likely to receive an intracranial pressure monitor or hyperosmolar therapy than children in the 2000 cohort; however, about 10% of children without monitors received therapies to decrease intracranial pressure. This suggests treatment heterogeneity in children 24 months old or younger with traumatic brain injury and a need for better evidence to support treatment recommendations for this group of children.

Project description:BackgroundIndividuals who have experienced mild traumatic brain injuries (mTBIs) suffer from several comorbidities, including chronic pain. Despite extensive studies investigating the underlying mechanisms of mTBI-associated chronic pain, the role of inflammation in long-term pain after mTBIs is not fully elucidated. Given the shifting dynamics of inflammation, it is important to understand the spatial-longitudinal changes in inflammatory processes following mTBIs and their effects on TBI-related pain.MethodsWe utilized a recently developed transgenic caspase-1 luciferase reporter mouse model to monitor caspase-1 activation through a thinned skull window in the in vivo setting following three closed-head mTBI events. Organotypic coronal brain slice cultures and acutely dissociated dorsal root ganglion (DRG) cells provided tissue-relevant context of inflammation signal. Mechanical allodynia was assessed by mechanical withdrawal threshold to von Frey and thermal hyperalgesia withdrawal latency to radiant heat. Mouse grimace scale (MGS) was used to detect spontaneous or non-evoked pain. In some experiments, mice were prophylactically treated with MCC950, a potent small molecule inhibitor of NLRP3 inflammasome assembly to inhibit injury-induced inflammatory signaling. Bioluminescence spatiotemporal dynamics were quantified in the head and hind paws, and caspase-1 activation was confirmed by immunoblot. Immunofluorescence staining was used to monitor the progression of astrogliosis and microglial activation in ex vivo brain tissue following repetitive closed-head mTBIs.ResultsMice with repetitive closed-head mTBIs exhibited significant increases of the bioluminescence signals within the brain and paws in vivo for at least one week after each injury. Consistently, immunoblotting and immunofluorescence experiments confirmed that mTBIs led to caspase-1 activation, astrogliosis, and microgliosis. Persistent changes in MGS and hind paw withdrawal thresholds, indicative of pain states, were observed post-injury in the same mTBI animals in vivo. We also observed enhanced inflammatory responses in ex vivo brain slice preparations and DRG for at least 3 days following mTBIs. In vivo treatment with MCC950 significantly reduced caspase-1 activation-associated bioluminescent signals in vivo and decreased stimulus-evoked and non-stimulus evoked nociception.ConclusionsOur findings suggest that the inflammatory states in the brain and peripheral nervous system following repeated mTBIs are coincidental with the development of nociceptive sensitization, and that these events can be significantly reduced by inhibition of NLRP3 inflammasome activation.

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Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging.

Publications

Trauma Bay Disposition of Infants and Young Children With Mild Traumatic Brain Injury and Positive Head Imaging.

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