Elsevier

World Neurosurgery

Volume 110, February 2018, Pages e1078-e1084
World Neurosurgery

Original Article
Serious Concomitant Injuries in Pediatric Patients with Severe Traumatic Brain Injury

https://doi.org/10.1016/j.wneu.2017.12.002Get rights and content

Background

Severe traumatic brain injury (TBI) is a leading cause of death among children. Although several studies have reported the negative effects of concomitant injuries on mortality in adults with TBI, their effect on pediatric patients remains unclear. Our objective was to describe the effect of serious concomitant injuries on outcomes in pediatric patients with severe TBI.

Methods

We identified pediatric patients (<18 years) with severe TBI between 2004 and 2015, through the Japan Trauma Data Bank. We excluded patients who had cardiopulmonary arrest on arrival and those whose main outcome (mortality) was missed from the analyses. Two groups with severe TBI were compared on the basis of the presence of serious concomitant injuries (maximum Abbreviated Injury Scale score ≥3 in regions other than the head) and adjusted for potential confounders using multiple logistic regression analysis.

Results

One-thousand-and-thirty-four participants were eligible for analysis, of which 472 had serious concomitant injuries. Pediatric patients with a serious concomitant injury had higher mortality. The probability difference was 11.5 (95% confidence interval [CI]: 6.1%–16.9%), which was greater than the mortality of 1.5 (95% CI: 1.2%–1.8%) observed in patients with a serious injury but not TBI. The presence of a serious concomitant injury was significantly associated with increased mortality, even after adjusting for possible confounders (adjusted odds ratio, 2.01; 95% CI, 1.40–2.89; P < 0.001).

Conclusion

Serious concomitant injuries are associated with higher mortality in pediatric patients with severe TBI, as a direct consequence, as well as due to concomitant injuries potentiating TBI pathobiology.

Introduction

Traumatic brain injury (TBI) affects up to 280 out of 100,000 children worldwide and is the leading cause of death among them.1, 2, 3, 4, 5 The mortality of pediatric patients with severe TBI ranges from 17%–33%,6, 7, 8 and accurate prognosis is important for the development of treatment strategies, allocation of health care resources, and counseling. Concomitant injuries are common among patients with severe TBI because of the high-impact nature of trauma. Although still controversial, an increasing number of clinical investigations are providing evidence suggesting that serious extracranial injuries increase mortality in TBI patients.9, 10, 11, 12, 13 However, those studies have caveats in the form of the wide range of ages of the patients enrolled. Considering the anatomic, physiologic, and pathologic differences between adults and pediatric patients, these 2 populations should be discussed separately. To date, few reports have demonstrated the effect of serious concomitant injuries on the outcomes of pediatric patients with severe TBI.14

The present study aimed to describe the prevalence of serious concomitant injuries, predilection region, and associated head injury, in addition to assessing their effects on outcomes, in pediatric patients with severe TBI.

Section snippets

Study Design and Data Collection

We performed a retrospective cohort study using data derived from the Japan Trauma Data Bank (JTDB), which was established in 2003 under the main auspices of the Japanese Association for the Surgery of Trauma (Trauma Registry Committee) and the Japanese Association for Acute Medicine (Committee for Clinical Care Evaluations). The aim of the JTDB is to collect nationwide trauma patient data including patient characteristics, vital signs on arrival, information on inspection and treatment,

Results

Of the 236,698 patients registered in the JTDB, 1305 met the initial study criteria. After 271 patients were excluded (176 due to cardiopulmonary arrest on arrival and 95 due to unknown outcomes), 1034 were ultimately eligible for the analysis (Figure 1). Of these, 472 patients (46%) had serious concomitant injuries. The number of body regions seriously injured was 1 (interquartile range, 1–2). The chest was predominantly the most common region of serious concomitant injury, as observed in 391

Discussion

This study investigated the prevalence of serious concomitant injuries, the associated factors, and their effects on the outcomes of pediatric patients with severe TBI, using a large nationwide database. The results showed that serious concomitant injuries were common and that pediatric patients with and without a serious concomitant injury had significantly different demographics and etiologies. Most importantly, serious concomitant injuries were independently associated with higher mortality.

Conclusion

In conclusion, our study suggests that serious concomitant injuries are common in pediatric patients with severe TBI and are independently associated with higher mortality. In clinical settings, these findings can be used to obtain more accurate prognoses and, thereby, aid in the formulation of treatment strategies, allocation of health care resources, and counseling. However, further research, addressing the concerns raised in the Discussion section is warranted.

Acknowledgments

We thank the Japanese Association for the Surgery of Trauma (Trauma Registry Committee) and the Japanese Association for Acute Medicine (Committee for Clinical Care Evaluations) for providing the required dataset.

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    Conflict of interest statement: The authors report no conflict of interest. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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