Page 50 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Pediatric patients
Four studies contained pediatric patients, with one using prospectively collected data (Table V).55-58
Brain Trauma Foundation (BTF) Guideline adherence for ICP monitoring in the pediatric cohort was low. Close to 8% of patients meeting criteria was actually monitored and monitoring only showed mortality reduction in patients with a GCS of 3 (OR0.64, 95% CI 0.43-1.00).57 ICP-monitoring was related to significant longer ICU and hospital LOS (12.6 vs. 6.3 and 21.0 vs. 10.4 days) and higher costs.57
Although unfavorable outcome (up to 71.6%) and mortality rates were high (range 36-56.7%), favorable outcome was achieved in 40% to 45% of the patients.55, 56, 58 In patients with postresuscitation GCS Score 3 and 4; one-year survival was 43.3%, of which almost 12% was normal in every respect and 3% scored GOS=5.55
One article mentioned GCS ≤5 to be a significant predictor for poor outcome.56 Another stated that compared to the GCS 4 patient group, patients with a GCS=3 showed significantly more hypoxia (65.9% vs. 39.1%), single seizure (2.3% vs. 17.4%) and open cisterns on CT scan (68.2% vs. 91.3%) but did not find a statistically significant difference in survival or outcome (P=0.2).55
A normal pupillary reaction resulted in 87% chance of survival, which dropped to 23% when at least one eye was abnormal. Pupillary abnormalities resulted in 1-year poor outcome (GOS 1-3) in 92% of cases and 0% good outcome (GOS ≥4) for the combination of absent pupillary reflex and hypothermia. Pupillary response was considered the factor most predictive of both survival and outcome.55
Other negatively correlated factors for survival seemed to be a delayed presentation >150 minutes (P=0.010), DC >4 h after hospital arrival (P=0.042), intraoperative blood loss >300 mL (P=0.001) and mechanism of injury (abuse), hypothermia, hypotension, major concurrent symptoms, midline shift on CT scan, and assessment of the fontanelle.55, 56
Penetrating brain injury
Three articles in our vs-TBI article selection focussed on PBI.48, 49, 59 In case of PBI by a firearm projectile, admission GCS of 3-5 resulted in a poor prognosis (GOS 1-3) in up to 94.11%.49 A second article, investigating gunshot wounds to the head, presents a
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