Early Resuscitation of Children With Moderate-to- Severe Traumatic Brain Injury

Transcription

1 Erly Resuscittion of Children With Moderte-to- Severe Trumtic Brin Injury WHAT S KNOWN ON THIS SUBJECT: Trumtic brin injury is the leding cuse of deth nd disbility in children. Postinjury hypotension nd hypoxi re believed to induce secondry brin injury nd re ssocited with incresed morbidity nd mortlity. WHAT THIS STUDY ADDS: Hypotension nd hypoxi re common events in peditric trumtic brin injury. One third of children re not properly monitored for hypotension or hypoxi, especilly if they re smll. Attempts to tret hypotension nd hypoxi significntly improve outcomes. bstrct OBJECTIVES: Trumtic brin injury is leding cuse of deth nd disbility in children. Guidelines hve been estblished to prevent secondry brin injury cused by hypotension or hypoxi. The purpose of this study ws to identify the prevlence, monitoring, nd tretment of hypotension nd hypoxi during erly (prehospitl nd emergency deprtment) cre nd to evlute their reltionship to vitl sttus nd neurologic outcomes t hospitl dischrge. METHODS: This ws retrospective study of 299 children with moderte-to-severe trumtic brin injury presenting to level 1 peditric trum center. We recorded vitl signs nd medicl provider response to hypotension nd/or hypoxi during ll portions of erly cre. RESULTS: Blood pressure (31%) nd oxygention (34%) were not recorded during some portion of erly cre. hypotension occurred in 118 children (39%). An ttempt to tret documented hypotension ws mde in 48% (57 of 118 children). After djusting for severity of illness, children who did not receive n ttempt to tret hypotension hd n incresed odds of deth of 3.4 nd were 3.7 times more likely to suffer disbility compred with treted hypotensive children. hypoxi occurred in 131 children (44%). An ttempt to tret hypoxi ws mde in 92% (121 of 131 children). Untreted hypoxi ws not significntly ssocited with deth or disbility, except in the setting of hypotension. CONCLUSIONS: Hypotension nd hypoxi re common events in peditric trumtic brin injury. Approximtely one third of children re not properly monitored in the erly phses of their mngement. Attempts to tret hypotension nd hypoxi significntly improved outcomes. Peditrics 2009;124:56 64 CONTRIBUTORS: Michelle Zebrck, MD, Christopher Dndoy, MD, b Kristine Hnsen, RN, BS, c Eric Scife, MD, d N. Cly Mnn, PhD, MS, e nd Susn L. Brtton, MD, MPH Divisions of Peditric Criticl Cre nd d Peditric Surgery nd e Intermountin Injury Control Reserch Center, University of Uth School of Medicine, Slt Lke City Uth; b Division of Peditrics, Mimi Children s Hospitl, Mimi, Florid; c Trum Progrm, Primry Children s Medicl Center, Slt Lke City, Uth KEY WORDS trumtic brin injury, secondry brin injury, outcome, emergency deprtment, emergency resuscittion, tretment, emergency medicl services ABBREVIATIONS TBI trumtic brin injury ED emergency deprtment PCMC Primry Children s Medicl Center GCS Glsgow Com Scle EMS emergency medicl services ISS Injury Severity Score CT computed tomogrphy GOS Glsgow Outcome Scle RR reltive risk CI confidence intervl OR djusted odds rtio doi: /peds Accepted for publiction Nov 6, 2008 Address correspondence to Michelle Zebrck, MD, 295 Chipet Wy, PO Box , Slt Lke City, UT E-mil: michelle.zebrck@hsc.uth.edu PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2009 by the Americn Acdemy of Peditrics FINANCIAL DISCLOSURE: The uthors hve indicted they hve no finncil reltionships relevnt to this rticle to disclose. 56 ZEBRACK et l

2 ARTICLES Trumtic brin injury (TBI) is the leding cuse of injury-relted deth nd disbility in children nd is mjor public helth problem in the United Sttes. 1 Approximtely TBIs occur nnully in children 15 yers of ge. Ech yer, 2000 children die from TBI, nd require hospitliztion, 2 yet peditric TBI remins underinvestigted. 3 In ddition to the primry injury occurring t the moment of impct, secondry brin injury evolving over the ensuing minutes, hours, nd dys cn occur, resulting in incresed disbility nd mortlity. 4 For this reson, guidelines hve been published ddressing the prehospitl ssessment, tretment, nd trnsport of individuls with TBI. 3,4 Postinjury hypotension nd hypoxi re believed to induce secondry brin injury nd re ssocited with incresed morbidity nd mortlity Few peditric studies hve identified the prevlence of hypotension nd hypoxi during prehospitl nd emergency deprtment (ED) cre nd linked these episodes to outcomes t hospitl dischrge. There re limited dt regrding how well children re monitored nd treted for hypotension nd hypoxi during their erly cre. We hypothesized tht hypotension nd hypoxi in modertely nd severely brin-injured children re frequent occurrences in the prehospitl nd ED settings nd tht filure to respond to erly hypotension nd/or hypoxi is ssocited with worse outcome. METHODS Study Design A retrospective cohort study of children with moderte-to-severe TBI ws conducted from Jnury 2002 to September We identified ll ptients 15 yers of ge with moderte or severe TBI presenting to Primry Children s Medicl Center (PCMC), freestnding Peditric Americn College of Surgeons-ccredited level 1 trum center in Slt Lke City. PCMC serves 5 western sttes nd hd n nnul ED volume of ptients during the study period. Moderte TBI ws defined s postresuscittion Glsgow Com Scle (GCS) score 9 to 12. Severe TBI ws defined s postresuscittion GCS score 3 to 8. Postresuscittion GCS score ws defined s the score obtined on rrivl to the ED t PCMC. The University of Uth Institutionl Review Bord pproved this study nd wived the need for informed consent. Dt were bstrcted from the trum registry, hospitl medicl chrts, nd emergency medicl services (EMS) run sheets. Erly resuscittion ws defined s ll portions of cre from the time of injury until deprture from ED, including ground or ir trnsport from the scene, community medicl fcility tretment, interfcility trnsfer, nd ED cre. Vitl signs during ll portions of erly cre were recorded. Hypoxi ws defined s sturtion 90% or if pne 20 seconds ws documented. Hypotension ws defined s systolic blood pressure 5th percentile for the ge pproprite norm. 8,11 Lck of monitoring for blood pressure, oximetry, nd respirtory rte ws lso recorded by loction of cre. To evlute medicl provider response to hypotension or hypoxi/pne, dt were collected for ll of the ptient interventions. Medicl provider response to hypotension or hypoxi/pne ws independently evluted by 2 criticl cre physicins nd rted s treted or untreted. Tretment for hypotension ws defined s plcement of n introsseous or intrvenous ctheter nd dministrtion of fluid bove hourly mintennce rtes (Tble 1). For ptients with hypoxi, tretment for low oxygen sturtion required dministrtion of supple- TABLE 1 Hourly Mintennce Rtes Ptient s Weight Rnge, kg 10 Hourly Mintennce Fluid Rte 4 ml/kg per h ml/h plus 2 ml/kg per h for ech kg 10 kg ml/h plus 1 ml/kg per h for ech kg 20 kg mentl oxygen, nd tretment for pne required the use of bg msk ventiltion or intubtion. Correction of hypotension or hypoxi ws not required to chieve rting of treted. In cses where cre provider did not document blood pressure, respirtory rte, or sturtion, the ptient ws considered not fully monitored t tht site of cre. One set of vitl signs ws required during ech site of cre to be considered fully monitored. However, if hypotension or hypoxi ws documented, follow-up mesurement ws required to evlute ongoing tretment. Ptient injuries were enumerted nd n Injury Severity Score 12 (ISS) ws clculted. Computed tomogrphy (CT) scns obtined within the prehospitl/ed time period were reviewed nd grded using the Mrshll clssifiction 13 (Tble 2). TABLE 2 Mrshll Clssifiction of CT Scns 13 Level Clssifiction I No visible intrcrnil pthology II Diffuse injury with cisterns present nd 0- to 5-mm shift III Diffuse injury with cisterns compressed or bsent nd 0- to 5-mm shift IV Diffuse injury with midline shift 5 mm but no lesion 25 mm EML Evcuted mss lesion, ny surgiclly evcuted mss lesion NEML Nonevcuted mss lesion, ny high- or mixed-density mss lesion 25 mm not surgiclly evcuted EML indictes evcuted mss lesion; NEML, nonevcuted mss lesion. PEDIATRICS Volume 124, Number 1, July

3 TABLE 3 Chrcteristics of Children Ctegorized by Adequcy of Blood Pressure Monitoring Chrcteristic Fully Monitored All Sites Not Fully Monitored No Hypotension (N 129) Outcome Mesures The primry outcome mesures were mortlity nd functionl neurologic outcome t hospitl dischrge. Functionl neurologic outcome ws rnked s poor or fvorble bsed on the Glsgow Outcome Scle (GOS) score. The GOS rnges from 5 (good recovery) to 1 (deth). 14 We defined poor GOS score s 1 (ded), 2 (vegettive), or 3 (severely disbled), wheres fvorble GOS score ws defined s 4 (moderte disbility) or 5 (good recovery). Sttisticl Anlysis Dt were nlyzed using SPSS 15.0 for Windows (SPSS Inc, Chicgo, IL). Summry results were expressed s medins (with 25th nd 75th qurtiles) or Hypotension (N 77) No Hypotension (N 52) Hypotension (N 41) Age, y Medin b IQR Weight, kg Medin b IQR GCS score Medin IQR Trnsport time, min c Medin IQR PCMC ph d Medin b IQR ISS Medin IQR Length of sty ICU, d Medin IQR GOS score Medin b IQR Poor GOS score, n (%) e 10 (8) 33 (43) 13 (25) 29 (71) b Deth, n (%) 5 (4) 28 (36) 9 (17) 23 (56) b IQR indictes interqurtile rnge. P.05 compred with normotensive ptients in the fully monitored group. b P.05 compred with hypotensive ptients in the fully monitored group. c Dt exclude 2 cse subjects trnsported 24 hours fter injury. d Dt re missing 22 vlues. e Poor score ws defined s 1 3. percentges. Bivrite nlyses were conducted using 2 tests nd the Mnn- Whitney U test or Wilcoxon signed rnk test for continuous dt. Undjusted reltive risk (RR) rtios with 95% confidence intervls (CIs) were clculted. Sttisticl significnce ws defined s P.05. As prt of the multivrite nlysis pln, logistic regression models were developed for evluting potentil ssocitions between lck of vitl sign monitoring, s well s documented hypotension nd/or hypoxi, with poor neurologic outcome or deth, controlling for ptient nd injury chrcteristics. Four different models were constructed nd re summrized below. The first model evluted whether filure to fully monitor ptients ws ssocited with ptient demogrphics, clinicl chrcteristics, or outcome. A second model evluted potentil ssocitions between lck of vitl sign monitoring with poor neurologic outcome or deth. Third, medicl provider tretment of ptients with documented hypotension or hypoxi ws evluted by excluding the normotensive, nonhypoxic ptients nd designting subjects with treted hypotension or hypoxi s the comprison group. Finlly, relted model included both exposure to hypotension nd hypoxi/pne grded by provider tretment response to evlute the effects of both insults on clinicl outcomes. Ptients who did not hve documented hypotension or hypoxi, including those not fully monitored, were clssified s normotensive nd/or nonhypoxic in our nlyses. Vribles considered in the multivrite models included those tht were significntly ssocited with either lck of monitoring or the presence of hypotension or hypoxi in the bivrite nlysis. Severl severity-of-illness mrkers, such s Mrshll CT score, ISS, blood ph obtined in the ED t PCMC, nd postresuscittion GCS score, were evluted with the Spermn s correltion coefficient for colinerity. Mesures of illness severity with utocorreltions in excess of 0.35 were considered potentilly coliner nd were not both included in the sme model. ISS hd the gretest correltion with filure to fully monitor ptients, wheres Mrshll CT scores hd the gretest correltion with both mortlity nd poor outcome nd were, thus, retined in the finl models, which lso included blood ph in the ED t PCMC. Vribles were entered simultneously in the models. Blood ph ( 7.34, , nd 7.24) nd ISS ( 25, 18 25, nd 0 17) were grouped s trictegoricl dummy vrible 58 ZEBRACK et l

4 ARTICLES TABLE 4 Chrcteristics of Children Ctegorized by Adequcy of Sturtion nd Apne Monitoring Chrcteristics Fully Monitored All Sites Not Fully Monitored No Hypoxi/Apne (N 100) bsed on medin nd the lower 25th qurtile. The reference groups for the trictegoricl vribles were the highest ph nd lowest ISS groups. A pseudomesure of the vrince explined in the resulting logistic models ws represented s Ngelkerke s R 2. Model fit ws ssessed with the Hosmer nd Lemeshow test sttistic. Adjusted odd rtios (ORs) with 95% CIs were clculted. RESULTS Of the ptients evluted nd treted for hed injury during the study period, 311 ptients met criteri for hving moderte-to-severe hed injury. Twelve ptients were excluded becuse of missing EMS/run Hypoxi/ Apne (N 98) No Hypoxi/Apne (N 68) Hypoxi/ Apne (N 33) Age, y Medin IQR Weight, kg Medin IQR GCS score Medin IQR Trnsport time, min Medin b IQR PCMC ph c Medin IQR ISS Medin IQR Length of sty ICU, d Medin IQR GOS score Medin IQR Poor GOS score, n (%) d 7 (7) 51 (52) 9 (13) 18 (55) b Deth, n (%) 4 (4) 41 (42) 7 (10) 13 (39) b IQR indictes interqurtile rnge. Dt exclude 2 cse subjects trnsported 24 hours fter injury. b P.05 compred with hypotensive ptients in the fully monitored group. c Dt re missing 22 vlues. d Poor score ws defined s 1 3. sheets. No significnt difference in ge, GCS score, or GOS score ws found between the 12 excluded ptients nd the 299 included ptients. Of the 299 ptients, 245 (82%) hd severe TBI, nd 54 (18%) hd moderte TBI. The medin ge ws 6.5 yers, nd 60% were boys. Injuries mostly commonly occurred during the fternoon nd evening hours. Medin trnsport time ws 148 minutes. Cre ws provided by 187 different gencies from 5 western sttes. The most common mechnisms of trum were motor vehicle collisions (24%), flls (18%), nd inflicted injury (12%). The medin postresuscittion GCS score ws 3, nd the medin ISS ws 25. The mjority (94%) of children underwent CT imging during their prehospitl/ed course. Children who did not undergo CT imging died before it ws possible to imge or were tken directly to the operting room for surgicl intervention. Hypotension nd Monitoring Hypotension ws documented in 118 of 299 children (39%). Thirty-one percent of children were not monitored for blood pressure during portion of their erly cre. Most often (89%) this occurred during the scene EMS time period. hypotension ws lest likely to be treted t the scene (12%) nd most likely to be treted in the ED t PCMC (86%). Tble 3 enumertes ptient chrcteristics ctegorized by whether children were fully monitored for blood pressure t ll of the sites. The 2 popultions were further subdivided by the bsence or presence of documented hypotension. Children not fully monitored for blood pressure were younger nd smller thn fully monitored children. In children without documented hypotension, those who were not fully monitored hd n incresed risk of in-hospitl deth (RR: 4.5 [95% CI: ]) nd n incresed risk of poor GOS score t dischrge (RR: 3.2 [95% CI: ]) compred with children who were fully monitored. In the multivrite nlysis, fctors ssocited with blood pressure monitoring included ge (OR: 1.2 [95% CI: ]) nd severity of illness per the ISS, djusted for blood ph. Compred with children with ISS 0 to 17, those with scores 25 were less likely to hve blood pressure documented (OR: 0.4 [95% CI: ]). (Ngelkerke s R ) Thus, the bsence of blood pressure monitoring ws ssocited with young ge, incresed severity of illness, nd poor outcome. PEDIATRICS Volume 124, Number 1, July

5 TABLE 5 Chrcteristics of Children Ctegorized by Treted nd Untreted Hypotension Chrcteristic No Hypotension (N 181) Hypotension Hypoxi/Apne nd Monitoring Hypoxi or pne ws documented in 131 (44%) of 299 children. Thirty-four percent of children were not monitored for oxygen sturtion or pne during portion of their erly cre; most often this occurred t the scene (69%). hypoxi/pne lso occurred most often t the scene. EMS personnel treted hypoxi/pne 87% of the time. Air trnsport, community hospitl, nd PCMC ED personnel Tretment (N 57) No Tretment (N 61) Age, y Medin IQR Weight, kg Medin IQR GCS score Medin 4 3 b 3 b IQR Trnsport time, min c Medin IQR PCMC ph d Medin b 7.28 b IQR ISS Medin b 29 b IQR Mrshll score, n (%) 1 53 (29) 11 (19) 4 (7) b 2 66 (36) 16 (28) 17 (28) 3 29 (16) 15 (26) 19 (31) 4 2 (1) 2 (4) 2 (3) Evcuted mss lesion, n (%) 27 (15) 6 (11) 5 (8) Nonevcuted mss lesion, n (%) 3 (2) 1 (2) 3 (5) No CT performed, n (%) 1 (1) 6 (11) 11 (18) Length of sty ICU, d Medin b IQR GOS score Medin 5 4 b 1 b IQR Poor GOS score, n (%) e 23 (13) 22 (39) b 40 (65) b Deth, n (%) 14 (7) 17 (30) b 34 (56) b IQR indictes interqurtile rnge. Hypotension ws documented: it includes both ptients who were nd were not fully monitored. b Dt re significntly different from the nonhypotension group. c Dt exclude 2 cse subjects trnsported 24 hours fter injury. d Twenty-two vlues re missing. e Poor score ws defined s 1 3. treted hypoxi/pne 100% of the time. Tble 4 ddresses monitoring for hypoxi/pne. Children with hypoxi were significntly younger nd smller thn children without documented hypoxi. Children with hypoxi nd children who were not fully monitored hd lower medin GCS scores thn children without documented hypoxi who were fully monitored. Filure to monitor for hypoxi/pne ws not ssocited with ge, other mrkers of injury severity, trnsport time, or poor outcome. Response to Hypotension Tble 5 depicts provider response to hypotension s it reltes to ptient demogrphic nd clinicl chrcteristics. Ptients were ctegorized by presence or bsence of documented hypotension. Ptients without documented hypotension, including those who were not completely monitored, were clssified s normotensive. If hypotension ws documented, ptients were further subdivided by whether they were treted or untreted for hypotension. Of the 118 children with documented hypotension, 57 (48%) were treted. Hypotensive children were more likely to die nd hd more severe Mrshll CT scores, lower GCS scores, lower blood ph, nd higher ISS compred with children without documented hypotension. Children who were not treted for hypotension hd significntly higher undjusted risk of in-hospitl deth (RR: 1.9 [95% CI: ]) nd poor GOS scores t dischrge (RR: 1.7 [95% CI: ]) compred with treted children. In multivrite model, djusted for ph nd Mrshll CT scores, filure to tret documented hypotension ws ssocited with n incresed odds of deth (OR: [95% CI: ]) nd poor GOS score (OR: 3.7 [95% CI: ]) compred with treted children (Ngelkerke s R nd 0.590, respectively). Response to Hypoxi/Apne Tble 6 shows provider response to hypoxi or pne s it reltes to ptient demogrphic nd clinicl chrcteristics. The ptients were ctegorized by presence or bsence of documented hypoxi/pne nd were further subdivided by whether they were treted or untreted. Ptients without documented hypoxi, includ- 60 ZEBRACK et l

6 ARTICLES TABLE 6 Chrcteristics of Children Ctegorized by Treted nd Untreted Hypoxi/Apne Chrcteristic No Hypoxi/Apne (N 168) Hypoxi/Apne ing those who were not completely monitored, were clssified s nonhypoxic. Of the 131 children with documented hypoxi/pne, 121 (92%) were treted. Children with hypoxi/ pne were more likely to die nd were younger with more severe Mrshll CT scores, lower GCS scores, lower blood ph, nd higher ISS compred with children without documented hypoxi/ pne. The 10 children who were untreted for hypoxi/pne did not hve sttisticlly higher undjusted or djusted risk of deth or poor GOS score compred with treted children. Tretment (N 121) Hypotension nd Hypoxi Tretment nd Assocition With Outcomes No Tretment (N 10) Age, y Medin 8 5 b 6 IQR Weight, kg Medin b 18 IQR GCS score Medin 5 3 b 3 IQR Trnsport time, min c Medin b 81 b IQR PCMC ph d Medin b 7.29 b IQR ISS Medin b 26 IQR Mrshll score, n (%) 1 52 (31) 14 (12) b 2 (20) 2 65 (39) 34 (28) (15) 35 (29) 3 (30) 4 1 (1) 5 (4) 0 Evcuted mss lesion, n (%) 23 (14) 13 (11) 2 (20) Nonevcuted mss lesion, n (%) 2 (1) 5 (4) 0 No CT performed, n (%) 0 (1) 15 (12) 3 (30) Length of sty ICU, d Medin IQR GOS score Medin 5 3 b 1 b IQR Poor GOS score, n (%) e 16 (10) 62 (51) 7 (70) Deth, n (%) 11 (7) 48 (40) b 6 (60) b IQR indictes interqurtile rnge. Hypoxi/pne ws documented: this includes both ptients who were nd were not fully monitored. b Dt re significntly different from the nonhypoxic/pneic group. c Dt exclude 2 cse subjects trnsported 24 hours fter injury. d Twenty-two vlues re missing. e Poor score ws defined s 1 3. To further explore the ssocition mong hypoxi, hypotension, nd outcomes, models were developed (Tble 7) tht included both insults nd whether the providers treted hypotension nd/or hypoxi. Seventy-four children hd both documented hypotension nd hypoxi/pne. Children with treted hypotension were no more likely to die or hve poor GOS score thn children without hypotension, but children with untreted hypotension were significntly more likely to die (OR: 8.9 [95% CI: ]) or hve poor GOS score (OR: 11.6 [95% CI: ]) compred with children without hypotension. Children with hypoxi/pne hd worse GOS score whether they received tretment but were only more likely to die if they were untreted for hypoxi/pne (OR: 16.0 [95% CI: ]) compred with children without documented hypoxi or pne. DISCUSSION Our study demonstrtes tht erly hypotension nd hypoxi/pne re common events in peditric TBI nd re strongly ssocited with worse outcomes. More thn hlf of the children with documented hypotension nd 8% of children with documented hypoxi/ pne were untreted. Untreted children with hypotension were more likely to die or suffer severe disbility. When both hypotension nd hypoxi/ pne were present, untreted hypoxi/ pne ws lso ssocited with n incresed risk of deth nd disbility. Attempted tretment ws ssocited with improved outcome. Almost one third of children were not fully monitored in the prehospitl nd ED settings, especilly those who were younger nd sicker. Hypotension ws documented in 39% of our study popultion nd ws strongly ssocited with deth (Fig 1). These findings re similr to existing literture regrding brin-injured dults 5,7 nd children. 9,15,16 There is some evidence tht erly hypotension (field or ED) predicts worse outcome thn hypotension fter dmission to the PICU. 8 In our study, even in children who received tretment for erly hypotension, the risk of deth ws twice tht of children without documented hypotension. However, left untreted, children with erly hypotension were PEDIATRICS Volume 124, Number 1, July

7 TABLE 7 Presence of Hypoxi/Apne nd Hypotension: Tretment nd Outcomes Vrible OR CI In-hospitl deth No hypotension documented 1 Reference group Hypotension treted Hypotension untreted No hypoxi/pne documented 1 Reference group Hypoxi/pne treted Hypoxi/pne untreted Ngelkerke s R Poor GOS score No hypotension documented 1 Reference group Hypotension treted Hypotension untreted No hypoxi/pne documented 1 Reference group Hypoxi/pne treted Hypoxi/pne untreted Ngelkerke s R Models were djusted for Mrshll clssifiction, blood ph in PCMC ED, nd ptient ge in yers. FIGURE 1 Deth nd ttempt to tret documented hypotension. 9 times s likely to die compred with children without documented hypotension. If both hypoxi nd hypotension were present, treted hypotensive ptients did not hve worse outcomes thn ptients without hypotension, illustrting the importnce of tretment for hypotension. Hypoxi occurred in 44% of our ptients, finding similr to tht reported in other TBI studies. 5,7,9 Children with hypoxi hd significntly worse outcomes thn children without hypoxi, but we were unble to detect significnt difference in deth for the treted versus untreted groups, except in the nlysis tht djusted for the presence of both hypotension nd hypoxi, suggesting tht perhps the neurologic insult from hypoxi is dditive to the insult from hypotension (Fig 2). FIGURE 2 Deth nd ttempt to tret documented hypoxi. Although children were most likely to be hypotensive or hypoxic/pneic t the scene, they were lest likely to receive corrective interventions for these insults t the scene. Medicl providers t ll sites of cre were more likely to respond to hypoxi thn hypotension. This finding does not seem to be becuse of restrictions on obtining intrvenous or introsseous ccess. Resuscittion of criticlly injured children is dunting tsk, nd bsed on published reports, children represent 10% of life-thretening EMS prehospitl clls. 17,18 Su et l 18 reported tht children with hypotension nd tchycrdi were much less likely to receive n intrvenous ctheter during prehospitl mngement when compred with dults with similr bnorml physiologic prmeters. Lck of ongoing peditric trining for EMS personnel my be contributing fctor, nd lthough peditric skills hve been shown to deteriorte quickly without prctice, continuing eduction in peditric cre is often not required. 19,20 A prticulrly worrisome finding in our study ws the lck of consistent vitl sign monitoring, especilly in younger nd sicker children. Worse outcomes nd higher likelihoods of deth were noted in the unmonitored popultion. Children were lest likely to be fully monitored t the scene, where presumbly limited personnel were vilble to resuscitte, monitor, nd trnsport criticlly injured child. There were limittions in our study. Lck of complete documenttion of vitl signs by medicl providers my hve influenced our findings. Becuse vitl signs were not consistently documented t ll of the sites of cre, hypotension or hypoxi/pne my hve occurred more frequently thn we report. Incresed risk of poor outcomes in the unmonitored ptients without documented vitl sign instbility suggests tht unmonitored children were sicker, nd if vitl sign recording were more thorough, greter proportion of children would hve been clssified s hypotensive nd/or hypoxic. Thus, the ssocitions between hypotension nd hypoxi nd poor outcome or deth were likely underestimted. Medicl provider response to hypotension nd hypoxi/ pne ws evluted by consensus of 2 criticl cre physicins. We ttempted to minimize subjective error by clerly defining the requirements for tretment. Medicl providers were not expected to correct hypotension or hypoxi/pne but rther to respond to nd tret hypotension or hypoxi/ pne. Although we controlled for injury severity on the multivrite models, this my not sufficiently control for 62 ZEBRACK et l

8 ARTICLES risk of deth or poor outcome. We did not collect ED length of sty dt. CONCLUSIONS TBI is one of the most common disbling injuries in children. Adequte resuscittion is criticl. All medicl providers involved in the cre of brin-injured children must be prepred to recognize nd respond to hypotension nd hypoxi/ pne. The initil interventions re strightforwrd. For hypotension, plce n intrvenous or introsseous ctheter nd dminister bolus isotonic fluid For hypoxi, provide oxygen. For pne, ventilte vi bg msk or endotrchel intubtion. As Chesnut et l 7 eloquently pointed out more thn decde go, we see before us clinicl problem where ny improvement hs the potentil of mking significnt impct on the outcome from hed injury. Fifteen yers lter, we re fced with the sme chllenge. ACKNOWLEDGMENTS This work ws supported by coopertive greement (U07MC05036) from the Emergency Medicl Services for Children Progrm in the Helth Resources nd Services Administrtion (Rockville, MD). We cknowledge nd extend our grtitude to the trum service nurse prctitioners t Primry Children s Medicl Center who worked diligently to help complete this project. REFERENCES 1. Lnglois JA, Rutlnd-Brown W, Wld MM. The epidemiology nd impct of trumtic brin injury: brief overview. J Hed Trum Rehbil. 2006;21(5): Rutlnd-Brown W, Lnglois JA, Thoms KE, Xi XL. Incidence of trumtic brin injury in the United Sttes, J Hed Trum Rehbil. 2006;21(6): Adelson PD, Brtton SL, Crney NA, et l. Guidelines for the cute medicl mngement of severe trumtic brin injury in infnts, children, nd dolescents: chpter 1 introduction. Peditr Crit Cre Med. 2003;4(3 suppl):s2 S4 4. Gbriel EJ, Ghjr J, Jgod A, Pons PT, Scle T, Wlters BC. Guidelines for prehospitl mngement of trumtic brin injury. J Neurotrum. 2002;19(1): Mnley G, Knudson MM, Morbito D, Dmron S, Erickson V, Pitts L. Hypotension, hypoxi, nd hed injury: frequency, durtion, nd consequences. Arch Surg. 2001;136(10): Chi JH, Knudson MM, Vssr MJ, et l. Prehospitl hypoxi ffects outcome in ptients with trumtic brin injury: prospective multicenter study. J Trum. 2006;61(5): Chesnut RM, Mrshll LF, Kluber MR, et l. The role of secondry brin injury in determining outcome from severe hed injury. J Trum. 1993;34(2): Cotes BM, Vvill MS, Mck CD, et l. Influence of definition nd loction of hypotension on outcome following severe peditric trumtic brin injury. Crit Cre Med. 2005;33(11): Pigul FA, Wld SL, Shckford SR, Vne DW. The effect of hypotension nd hypoxi on children with severe hed injuries. J Peditr Surg. 1993;28(3): Kokosk ER, Smith GS, Pittmn T, Weber TR. Erly hypotension worsens neurologicl outcome in peditric ptients with modertely severe hed trum. J Peditr Surg. 1998;33(2): Americn Hert Assocition for Crdiopulmonry Resuscittion nd Emergency Crdiovsculr Cre. Prt 12: peditric dvnced life support. Circultion. 2005;112(24 suppl):iv-167 IV Bker SP, O Neill B, Hddon W Jr, Long WB. The injury severity score: method for describing ptients with multiple injuries nd evluting emergency cre. J Trum. 1974;14(3): Mrshll LF, Mrshll SB, Kluber MR, et l. The dignosis of hed injury requires clssifiction bsed on computed xil tomogrphy. J Neurotrum. 1992;9(suppl 1):S287 S King JT Jr, Crlier PM, Mrion DW. Erly Glsgow Outcome Scle scores predict long-term functionl outcome in ptients with severe trumtic brin injury. J Neurotrum. 2005;22(9): Vvill MS, Bowen A, Lm AM, et l. Blood pressure nd outcome fter severe peditric trumtic brin injury. J Trum. 2003;55(6): Chiretti A, Pistr M, Pulitno S, et l. Prognostic fctors nd outcome of children with severe hed injury: n 8-yer experience. Childs Nerv Syst. 2002;18(3 4): Tsi A, Kllsen G. Epidemiology of peditric prehospitl cre. Ann Emerg Med. 1987;16(3): Su E, Mnn NC, McCll M, Hedges JR. Use of resuscittion skills by prmedics cring for criticlly injured children in Oregon. Prehosp Emerg Cre. 1997;1(3): Su E, Schmidt TA, Mnn NC, Zechnich AD. A rndomized controlled tril to ssess decy in cquired knowledge mong prmedics completing peditric resuscittion course. Acd Emerg Med. 2000;7(7): Institute of Medicine Committee on the Future of Emergency Cre in the United Sttes Helth PEDIATRICS Volume 124, Number 1, July

9 System. Emergency Cre for Children: Growing Pins. Future of Emergency Cre. Wshington, DC: Ntionl Acdemies Press; 2007:xxii, Bnerjee S, Singhi SC, Singh S, Singh M. The introsseous route is suitble lterntive to intrvenous route for fluid resuscittion in severely dehydrted children. Indin Peditr. 1994; 31(12): Gleser PW, Hellmich TR, Szewczug D, Losek JD, Smith DS. Five-yer experience in prehospitl introsseous infusions in children nd dults. Ann Emerg Med. 1993;22(7): Buck ML, Wiggins BS, Sesler JM. Introsseous drug dministrtion in children nd dults during crdiopulmonry resuscittion. Ann Phrmcother. 2007;41(10): ZEBRACK et l

10 Erly Resuscittion of Children With Moderte-to-Severe Trumtic Brin Injury Michelle Zebrck, Christopher Dndoy, Kristine Hnsen, Eric Scife, N. Cly Mnn nd Susn L. Brtton Peditrics 2009;124;56 DOI: /peds Updted Informtion & Services References Cittions Post-Publiction Peer Reviews (P 3 Rs) including high resolution figures, cn be found t: /content/124/1/56.full.html This rticle cites 22 rticles, 1 of which cn be ccessed free t: /content/124/1/56.full.html#ref-list-1 This rticle hs been cited by 3 HighWire-hosted rticles: /content/124/1/56.full.html#relted-urls One P 3 R hs been posted to this rticle: /cgi/eletters/124/1/56 Subspecilty Collections Permissions & Licensing Reprints This rticle, long with others on similr topics, ppers in the following collection(s): Emergency Medicine /cgi/collection/emergency_medicine_sub Trum /cgi/collection/trum_sub Informtion bout reproducing this rticle in prts (figures, tbles) or in its entirety cn be found online t: /site/misc/permissions.xhtml Informtion bout ordering reprints cn be found online: /site/misc/reprints.xhtml PEDIATRICS is the officil journl of the Americn Acdemy of Peditrics. A monthly publiction, it hs been published continuously since PEDIATRICS is owned, published, nd trdemrked by the Americn Acdemy of Peditrics, 141 Northwest Point Boulevrd, Elk Grove Villge, Illinois, Copyright 2009 by the Americn Acdemy of Peditrics. All rights reserved. Print ISSN: Online ISSN:

11 Erly Resuscittion of Children With Moderte-to-Severe Trumtic Brin Injury Michelle Zebrck, Christopher Dndoy, Kristine Hnsen, Eric Scife, N. Cly Mnn nd Susn L. Brtton Peditrics 2009;124;56 DOI: /peds The online version of this rticle, long with updted informtion nd services, is locted on the World Wide Web t: /content/124/1/56.full.html PEDIATRICS is the officil journl of the Americn Acdemy of Peditrics. A monthly publiction, it hs been published continuously since PEDIATRICS is owned, published, nd trdemrked by the Americn Acdemy of Peditrics, 141 Northwest Point Boulevrd, Elk Grove Villge, Illinois, Copyright 2009 by the Americn Acdemy of Peditrics. All rights reserved. Print ISSN: Online ISSN: