Page 52 - DECISION-MAKING IN SEVERE TRAUMATIC BRAIN INJURY PATIENT OUTCOME, HOSPITAL COSTS, AND RESEARCH PRACTICE

Chapter 2
Tabel V Pediatric Patients
Study Information
Fulkerson (2015)55 USA, 1988-2004 Prospective
Khan (2014)56 Pakistan, 2000-2010 Retrospective
Alkhoury (2014)57 USA, 2001-2006 Retrospective
Guresir (2012)58 Germany, 2000-2009 Retrospective
Purpose
Clinical outcome in children with TBI.
Risk factors in pediatric patients with DC.
Effect of ICP monitoring on survival in s-TBI.
Outcome of
DC for sustained high ICP.
Population
N=67
1: GCS3:44 2: GCS4:23
N=25 GCS3-5:11 BE 80% ASDH 24%
N=4141 GCS3: 1942 GCS4: 167 GCS5: 169
N=34
DC for TBI: 23 (67.7%)
♂
60
84 62 60
Age
1: 49,8M 2: 66.9M
6 ±8.6 12
Type of GCS score
Post- resuscitation (Modified for pediatric)
Presentation
Emergency department
Admission
Pupils
Asymmetry: 1: 20.4%
2: 13.0%
Anisocoria: 24% NP
Normal=6 UDP=7 BDP=10
Table V: Abbreviations: ♂: Male; ASDH: Acute Subdural Hematoma; BDP: Bilateral Dilated Pupils; BE: Brain Edema; DBS: Diffuse Brain Swelling; DC: Decompressive Craniectomy; EVD: Extraventricular Drain; GCS: Glasgow Coma Scale; GOS: Glasgow Outcome Scale; ICP: Intracranial Pressure; mRS: modified Rankin Scale; NP: Not provided; R-ICH: Refractory Intracranial Hypertension; s-TBI: severe Traumatic Brain Injury; TBI: Traumatic Brain Injury; UDP: Unilateral dilated pupil.
Table VI: Differences Civilian & Military patients suffering PBI
Age
Cause Mechanism Time to hospital Protection
GCS
Mortality
Civilian
All
GSW – near contact injury (self-)assault
30-45 minutes
None
lower
19-88%
Military
Young, healthy
Explosion; low-velocity shell/shrapnel injury Mainly explosive blasts
Up to 2,5 hours
Body armor and helmets
higher
5-30%
Table VI: Abbreviations: GSW: gunshot wounds; GCS: Glasgow Coma Scale
Over the past decades multiple studies have been published suggesting a less aggressive approach, with an important adjuvant role for antibiotics.77, 80-82 However, more recently, Charry et al. suggested that early DC as a damage control procedure in civilian patients suffering PBI in a hospital setting with limited resources on ICU neuro- monitoring is a treatment option to improve survival and outcome in these patients.83 Rapid exploration and exenteration of the injured air sinuses is recommended to prevent infectious complications 84,85. CSF fistulas pose a very high risk for deep infections 67, 69, 78 with nosocomial organisms and should be closed watertight, and if needed with placement of lumbar drainage.82
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