During the study period, 454 children were admitted in our ICU for traumatic HI. They were all included in this study.
This represented 33% of all pediatric ICU admissions and 84% of pediatric post-traumatic cases admitted in our ICU. The transport and the stabilization of vital functions were performed by a prehospital system and/or fire fighters in 37% of cases. However, in 63% of cases, the transport was performed by patient's family.
Of all patients coming, 32.3% were from Sfax city or its delegations. However, a significant number of children (67.7%) were referred to us from south Tunisia cities. There were 313 male (68.9%) and 141 female patients with a mean age (±SD) of 7.2±3.8 years
The demographic and clinical parameters on admission are shown in .
Demographic and clinical parameters on admission of all study population
Trauma was caused by traffic accident (69.4%), domestic accidents (29.7%), or was due to assault (0.2%).
Extracranial pathology was present in 38.7% of patients including ribs or long bones fracture (25.1%), chest trauma (9.5%), abdominal trauma (14.3%), pelvic trauma (4.4%) and spinal trauma (1.3%).
In this study, brain CT-Scan was performed on admission in 446 patients; however, for eight patients the brain was explored on admission by MRI.
Four hundred and twenty-four patients (93.4%) needed intubation on the scene of the accident and the remaining patients were intubated at their admission, mechanical ventilation (mean duration 4.3±5.6 days) and sedation on admission according to the protocols detailed above.
On admission, 91(20%) patients needed craniotomy, the most observed surgical interventions were: evacuation of a subdural hematoma (N=8), evacuation of an extradural hematoma (N=30), lobectomy (N=3), cerebrospinal fluid drainage (N=3), elevation of depressed skull fracture (N=36) and decompressive craniectomy (N=1). Moreover, 40 needed immediately extracranial surgery.
The results of brain CT-scan are presented in . According to Marshall tomographic grading “Traumatic Coma Data Bank classification” we had 31.9% type I, 41% type II, 9.9% type III, 1.3% type IV, 12.1% type V and 3.7% type VI.
Cerebral CT scan findings in our series
During the ICU stay, 314 patients (69.2%) had complications: 83 patients (18.3%) developed nosocomial infections in 108 episode: pneumonia 58(53.7%), tract urinary infection 16(14.8%), meningitis 9(8.3%), septicemia 8(7.4%) and inner ear infection or sinusitis 9(8.4%).
Moreover, 172 patients (37.8%) developed arterial hypotension requiring fluid resuscitation, catecholamine were used in 28 patients (6.1%).
A total of 219 patients (48.2%) had rhabdomyolysis (CPK >500 IU/l).[27
] Hyponatremia (<130 mmol/l) was present in 77(17%), hypernatremia (>145 mmol/l) in 54(11.9%), diabetes insipidus in 5(1.1%), fat embolism in 2(0.4%), stage III or IV ulcer[28
] in 15(3.3%), neurogenic pulmonary edema in 8(1.8%) and gastrointestinal hemorrhage in 6(1.3%).
During the ICU stay 377 patients (83%) developed SSIs. shows the frequency of each SSI.
Frequency of each secondary systemic insult
Mean ICU stay was 6.8±11.8 days and mean hospital stay was 11.9±15.8 days.
A total of 82 patients (18.1%) died. Regarding the time of death, the mortality percentage was 45.1% in the first 24-48 hours, 35.3% between 3 and 7 days and only 19.6% thereafter . Brain herniation (diagnosed clinically) was the main cause of mortality (80.4%). The GOS performed within a mean delay at 7±16 months after hospital discharge (range 0.5 and 96 months) were as follow: 82 deaths (18.1%), five vegetative state (1.1%) and 281 good recovery (61.9%) . Moreover, neuropsychiatric sequelae were observed in 143 patients (31.4%). The most observed sequel were motor deficit in 69 patients (15%), post-concussion syndrome including headaches, personality changes (anxiety, irritability), dizziness or impaired memory and concentration was observed in 36 patients (9.7%), dysarthria in 29(7.8%), lack of motor coordination and/or difficulty balancing in 23(6.2%), blurred vision or tired eyes in 21(5.7%), sensorial deficit in 13(3.5%), post-traumatic epilepsy in 11(3%), scholarly difficulties in 10(2.2%) and incontinence and/or bowel disorders in 7(2%).
Outcome in patient with severe head injury according to the Glasgow outcome scale
Univariate analysis showed that factors associated with a bad outcome according the GOS 2 were: low PTS on admission, high ISS, high PRISM, presence of shock, menigeal hemorrhage, cerebral edema, high blood sugar level on admission and bilateral mydriasis . Moreover, the majority SSIswere associated with a poor outcome .
Factors associated with bad outcome in univariate analysis
Association between each secondary systemic insult and outcome
Finally in our study, sodium level >145 mmol/l on ICU admission and during ICU stay was associated with poor outcome (P<0.0001). Moreover a severe hypornatremia <125 mmol/l was also associated with poor outcome (P<0.01) .
Association between dysnatremia [on admission; 12 hours after ICU admission (H12); ….] and bad outcome
In addition a blood sodium level >145 mmol/l was significantly associated with hyperglycemia (P=0.04), high value of PRISM (21.5±11.7 vs. 10.2±7; P<0.001); high value of ISS (31.5±9.3 vs 26.1±8.5; P<0.001) and a low value of GCS on admission (6.9±3.2 vs. 8.5±2.9; P=0.002).
The multivariate analysis showed that factors associated with a poor prognosis (GOS 2) were PRISM ≥24 (P=0.03; OR:5.75); GCS score ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR: 2.23); lesion type VI according Traumatic Coma Data Bank Classification (P=0.002; OR: 55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR:4.41).
A significant association was found between PRISM score and GOS(II), this model had a high discriminative power . In fact, PRISM score >24 was associated with poor outcomewith a sensitivity of 50%, a specificity of 81% and an area under the ROC curve at 0.83 . Moreover, PRISM score >24 was associated with a positive predictive value of GOS (II) of 96.5%and a negative predictive value of 82.9%.
Receiver operating characteristic curve (ROC curve) for ability of PRISM to predict the outcome. The area under the curve was 0.83 indicating a good capability of the model to discriminate between good and poor outcome
In addition, a low of GCS score on admission was associated with a poor outcome. In fact GCS score ≤8 was associated with bad outcome with a sensitivity of 50%, a specificity of 81% and an area under the ROC curve at 0.73. PTS was also discriminating with areas below the ROC curve at 0.73. However, ISS was not enough discriminating with areas below the ROC curve at 0.65.
Moreover blood glucose level on admission was significantly higher in patients with bad outcome (8.76±4.3 vs. 10.52±6.9 mmol/l; P=0.003) when compared with patients with a good outcome (GOS(I)).
As shown in , the outcome was significantly correlated with the number of organ failure (P<0.001). In fact, the bad rate was increased from 30.4% in patients with a number of organ failure less than 3-69.6% in those having more than three organ failure .
Association between the number of organ failure and outcome
Finally, according to “Traumatic Coma Data Bank” classification, mortality rate was at 11.7% in type I group, 16.6% in type II, 42% in type III, 66% in type IV, 27% in type V and 94% in type VI (P<0.0001) .
Outcome according to Traumatic Coma Databank classification of lesions