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1.  Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations 
To determine factors associated with poor outcome in children suffering traumatic head injury (HI).
Materials and Methods:
A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.
There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to 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 proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.
PMCID: PMC3132359  PMID: 21769206
Acute head injury; children; Glasgow coma scale score; intensive care unit; multivariate analysis; prognosis; trauma
2.  Ventilator-associated pneumonia in trauma patients with open tracheotomy: Predictive factors and prognosis impact 
To assess the predictive factors of ventilator associated pneumonia (VAP) occurrence following open tracheotomy in trauma patients.
Materials and Methods:
We conducted an observational, prospective study over 15 months, between 01/08/2010 and 30/11/2011. All trauma patients (except those with cervical spine trauma), older than 15 years, undergoing open tracheotomy during their ICU stay were included. All episode of VAP following tracheotomy were recorded. Predictive factor of VAP onset were studied.
We included 106 patients. Mean age was 37.9 ± 15.5 years. Mean Glasgow coma Scale (GCS) was 8.5 ± 3.7 and mean Injury Severity Score (ISS) was 53.1 ± 23.8. Tracheotomy was performed for 53 patients (50%) because of prolonged ventilation whereas 83 patients (78.3%) had tracheotomy because of projected long mechanical ventilation. Tracheotomy was performed within 8.6 ± 5.3 days. Immediate complications were bleeding events (22.6%) and barotrauma (0.9%). Late complications were stomal infection (28.3%) and VAP (52.8%). In multivariate analysis, independent factors predicting VAP onset were delayed tracheotomy (OR = 0.041; CI95% [1.02-7.87]; P = 0.041) and stomal infection (OR = 3.04; CI95% [1.02-9.93]; P = 0.045). Thirty three patients died in ICU (31.1%) without significant impact of VAP on mortality.
Late tracheotomy and stomal infection are independent factors predicting VAP onset after open tracheotomy in trauma patients. The occurrence of VAP prolongers mechanical ventilation duration and intensive care unit (ICU) length of stay (LOS) but doesn’t increase mortality.
PMCID: PMC3841530  PMID: 24339656
Multiple trauma; prognosis; tracheotomy; ventilator associated pneumonia
3.  Severe injury mechanisms in two paediatric trauma centres: Determination of prevention priorities 
Paediatrics & Child Health  2008;13(3):165-170.
To meet community needs, injury prevention programs for children should be targeted to trends in objective data on mechanisms of injury. The aim of the present study was to identify the most important severe injury mechanisms.
The present study retrospectively reviewed severe paediatric trauma patients in two regional trauma centres. Injury prevention priority scores were computed using different severity measures – injury severity score (ISS), revised trauma score, trauma-related injury severity score, Glasgow Coma Scale (GCS) and mortality – to identify prevention priorities.
A total of 3732 children with severe injury were identified; mean age (±SD) was 9.0±5.2 years and 2469 (66.2%) were boys. The GCS was 7 or lower in 209 patients (5.6%) and the median ISS was 9. Overall, there were 77 deaths (2.1%). ‘Fall from height’ was the most frequent mechanism of injury, and ‘motor vehicle traffic injury’ resulted in the most severe injury. The most significant mechanisms of injury, using ISS, were ‘fall from height’, ‘motor vehicle traffic injury’, ‘pedestrian struck by motor vehicle’, ‘bicycle injuries’ and ‘child abuse’. Different priorities were identified depending on the severity measures used – ‘fall from height’ would be the priority with ISS, revised trauma score and trauma-related injury severity score; ‘motor vehicle traffic injury’ with mortality and ‘drowning/submersion’ with GCS. ‘Fall from height’ was the highest ranked mechanism of injury in one centre compared with ‘motor vehicle traffic injury’ in the other. Younger children tended to have injuries as a result of falls, while adolescents had more motor vehicle occupant injuries. Failure to use safety devices, such as helmets and seat belts, was a common finding among severely injured children.
The present study shows that the severe injury prevention priorities identified vary depending on the severity measures used. The variations seen across age groups and between the two centres are also important factors that must be taken into account when developing prevention programs or considering research initiatives.
PMCID: PMC2529412  PMID: 19252692
Child; Epidemiology; Injury; Paediatrics; Prevention; Trauma registry
4.  Prevalence of Comorbidity and its Association with Traumatic Brain Injury and Outcomes in Older Adults 
The study aims were to examine the association between age, comorbidity, and cause of injury in older adults with traumatic brain injury (TBI); and to determine which comorbidities relate to mortality, length of stay, and functional outcome at hospital discharge, controlling for initial injury severity, age, and sex. A retrospective cohort study design was used; clinical and outcome trauma registry data were obtained for 196 adults 55 and older with TBI. The majority had at least one comorbid condition (e.g., hypertension, alcohol abuse). In-hospital mortality was 31%. Among the oldest-old, motor vehicle collisions and falls were significantly associated with specific chronic diseases. Prior myocardial infarction was significantly associated with an increased risk of in-hospital death. Injury Severity Score and Glasgow Coma Scale score were predictive of discharge function, but comorbidity did not add significantly to the model. Primary TBI prevention efforts in older adults must consider the impact of comorbidity and cause of injury, particularly in the oldest-old. Alcohol abuse is common in older adults with TBI; screening should be conducted and interventions developed to prevent future injury. Future study is warranted to understand the interplay between pathophysiology of comorbid disease and injury and how to best manage rehabilitation within the context of aging.
PMCID: PMC3569845  PMID: 22165997
5.  Boarding Injuries: The Long and the Short of It 
As the popularity of longboarding increases, trauma centers are treating an increased number of high severity injuries. Current literature lacks descriptions of the types of injuries experienced by longboarders, a distinct subset of the skateboarding culture. A retrospective review of longboarding and skateboarding injury cases was conducted at a level II trauma center from January 1, 2006, through December 31, 2011. Specific injuries in addition to high injury severity factors (hospital and intensive care unit (ICU) length of stay (LOS), Injury Severity Score (ISS), patient treatment options, disposition, and outcome) were calculated to compare longboarder to skateboarder injuries. A total of 824 patients met the inclusion criteria. Skull fractures, traumatic brain injuries (TBI), and intracranial hemorrhage (ICH) were significantly more common among longboard patients than skateboarders (P < 0.0001). All patients with an ISS above 15 were longboarders. Hospital and ICU LOS in days was also significantly greater for longboarders compared with skateboarders (P < 0.0001). Of the three patients that died, each was a longboarder and each experienced a head injury. Longboard injuries account for a higher incidence rate of severe head injuries compared to skateboard injuries. Our data show that further, prospective investigation into the longboarding population demographics and injury patterns is necessary to contribute to effective injury prevention in this population.
PMCID: PMC3934587  PMID: 24660063
6.  Prospective study of post-traumatic stress disorder in children involved in road traffic accidents 
BMJ : British Medical Journal  1998;317(7173):1619-1623.
To determine the prevalence of severe psychological trauma—that is, post-traumatic stress disorder—in children involved in everyday road traffic accidents.
12 month prospective study.
Accident and emergency department, Royal United Hospital, Bath.
119 children aged 5-18 years involved in road traffic accidents and 66 children who sustained sports injuries.
Main outcome measure
Presence of appreciable psychological distress; fulfilment of diagnostic criteria for post-traumatic stress disorder.
Post-traumatic stress disorder was found in 41 (34.5%) children involved in road traffic accidents but only two (3.0%) who sustained sports injuries. The presence of post-traumatic stress disorder was not related to the type of accident, age of the child, or the nature of injuries but was significantly associated with sex, previous experience of trauma, and subjective appraisal of threat to life. None of the children had received any psychological help at the time of assessment.
One in three children involved in road traffic accidents was found to suffer from post-traumatic stress disorder when they were assessed 6 weeks after their accident. The psychological needs of such children after such accidents remain largely unrecognised.
Key messagesOne in three children involved in everyday road traffic accidents was found to suffer from post-traumatic stress disorderPost-traumatic stress disorder was experienced by children of all ages, although girls were most likely to be affectedNeither the type of accident nor the nature and severity of the physical injuries were related to the presence of post-traumatic stress disorderThe child’s personal appraisal of the accident was important, with those children perceiving the event as life threatening being more likely to develop post-traumatic stress disorderThe psychological needs of children involved in road traffic accidents largely remain unrecognised
PMCID: PMC28739  PMID: 9848900
7.  Glasgow Coma Scale score at intensive care unit discharge predicts the 1-year outcome of patients with severe traumatic brain injury 
To analyse the association between the Glasgow Coma Scale (GCS) score at intensive care unit (ICU) discharge and the 1-year outcome of patients with severe traumatic brain injury (TBI).
Retrospective analysis of prospectively collected observational data.
Between 01/2001 and 12/2005, 13 European centres enrolled 1,172 patients with severe TBI. Data on accident, treatment and outcomes were collected. According to the GCS score at ICU discharge, survivors were classified into four groups: GCS scores 3–6, 7–9, 10–12 and 13–15. Using the Glasgow Outcome Scale (GOS), 1-year outcomes were classified as “favourable” (scores 5, 4) or “unfavourable” (scores <4). Factors that may have contributed to outcomes were compared between groups and for favourable versus unfavourable outcomes within each group.
Main results
Of the 538 patients analysed, 308 (57 %) had GCS scores 13–15, 101 (19 %) had scores 10–12, 46 (9 %) had scores 7–9 and 83 (15 %) had scores 3–6 at ICU discharge. Factors significantly associated with these GCS scores included age, severity of trauma, neurological status (GCS, pupils) at admission and patency of the basal cisterns on the first computed tomography (CT) scan. Favourable outcome was achieved in 74 % of all patients; the rates were significantly different between GCS groups (93, 83, 37 and 10 %, respectively). Within each of the GCS groups, significant differences regarding age and trauma severity were found between patients with favourable versus unfavourable outcomes; neurological status at admission and CT findings were not relevant.
The GCS score at ICU discharge is a good predictor of 1-year outcome. Patients with a GCS score <10 at ICU discharge have a poor chance of favourable outcome.
PMCID: PMC3675268  PMID: 23762202
Traumatic brain injury; Severe; Glasgow Coma Scale score; Glasgow Outcome Scale score; Long-term outcomes
8.  Pediatric and Youth Traffic-Collision Injuries in Al Ain, United Arab Emirates: A Prospective Study 
PLoS ONE  2013;8(7):e68636.
To study the mechanism of road traffic collisions (RTC), use of safety devices, and outcome of hospitalized pediatric and youth RTC injured patients so as to give recommendations regarding prevention of pediatric RTC injuries.
All RTC injured children and youth (0–19-year-olds) who were admitted to Al Ain City’s two major trauma centers or who died after arrival to these centers were prospectively studied from April 2006 to October 2007. Demography of patients, road-user and vehicle types, crash mechanism, usage of safety devices, injured body regions, injury severity, Revised Trauma Score, Glasgow Coma Scale, intensive care unit admissions, hospital stay and mortality were analyzed.
245 patients were studied, 69% were vehicle occupants, 15% pedestrians, 9% motorcyclists and 5% bicyclists. 79% were males and 67% UAE citizens. The most common mechanism of RTC was rollover of vehicle (37%) followed by front impact collision (32%). 32 (13%) of vehicle occupants were ejected from car. 63% of ejected occupants and 70% of motorcyclists sustained head injuries. Only 2% (3/170) vehicle passengers used seatbelts and 13% (3/23) motorcyclists a helmet.
Male drivers and UAE nationals were at high risk of RTC as drivers and as motorcyclists. Ejection rate was high because safety restraint use was extremely low in our community. More education and law enforcement focusing especially on car/booster seat use is needed.
PMCID: PMC3701680  PMID: 23861931
9.  Identifying traumatic brain injury in patients with isolated head trauma: are arterial lactate and base deficit as helpful as in polytrauma? 
Emergency Medicine Journal : EMJ  2007;24(5):333-335.
Increase in lactate (LAC) within the central nervous system after head trauma is an established marker of traumatic brain injury (TBI).
To investigate the utility of arterial base deficit (BD) and LAC in identifying TBI in patients with isolated head injury (IHI).
Materials and methods
TBI was defined as Glasgow Coma Scale ⩽8, head Abbreviated Injury Severity Score >2 or brain haematoma on CT scan. Patients were divided into two groups: IHI with and without TBI. Data were reported as means (SDs). 131 patients with IHI were studied (mean (SD) age 39 (19) years, 78% male).
17% of the patients sustained TBI. The mean differences for arterial BD (0.65 mmol/l, 95% CI −0.8 to 2.1) and LAC (0.34 mmol/l, 95% CI −0.7 to1.4) in patients with and without TBI were not significant. Analysis of receiver operating characteristic curves confirmed that arterial BD and LAC were unable to detect TBI in patients with IHI.
Arterial BD and LAC are poor predictors of TBI in isolated head trauma.
PMCID: PMC2658477  PMID: 17452699
10.  Hypothermia and Rapid Rewarming Is Associated With Worse Outcome Following Traumatic Brain Injury 
The purpose of the present study was to determine (1) the prevalence and degree of hypothermia in patients on emergency department admission and (2) the effect of hypothermia and rate of rewarming on patient outcomes.
Secondary data analysis was conducted on patients admitted to a level I trauma center following severe traumatic brain injury (n = 147). Patients were grouped according to temperature on admission according to hypothermia status and rate of rewarming (rapid or slow). Regression analyses were performed.
Hypothermic patients were more likely to have lower postresuscitation Glasgow Coma Scale scores and a higher initial injury severity score. Hypothermia on admission was correlated with longer intensive care unit stays, a lower Glasgow Coma Scale score at discharge, higher mortality rate, and lower Glasgow outcome score–extended scores up to 6 months postinjury (P < .05). When controlling for other factors, rewarming rates more than 0.25°C/h were associated with lower Glasgow Coma Scale scores at discharge, longer intensive care unit length of stay, and higher mortality rate than patients rewarmed more slowly although these did not reach statistical significance.
Hypothermia on admission is correlated with worse outcomes in brain-injured patients. Patients with traumatic brain injury who are rapidly rewarmed may be more likely to have worse outcomes. Trauma protocols may need to be reexamined to include controlled rewarming at rates 0.25°C/h or less.
PMCID: PMC3556902  PMID: 21157248
Complications; Function; Head injury; Length of stay; Mortality
11.  Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review 
Critical Care  2004;8(5):R347-R352.
Despite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.
The following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.
Of 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean ± standard error: 9.6 ± 1.2 days versus 18.7 ± 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 ± 1.2 days versus 21.0 ± 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 ± 1.2 days versus 4.9 ± 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).
Early tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.
PMCID: PMC1065024  PMID: 15469579
intensive care; mechanical ventilation; resource utilization; Saudi Arabia; trauma; tracheostomy; weaning
12.  Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database 
Critical Care  2006;10(Suppl 2):S2.
This report describes the case mix and outcome (mortality, intensive care unit (ICU) and hospital length of stay) for admissions to ICU for head injury and evaluates the predictive ability of five risk adjustment models.
A secondary analysis was conducted of data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme, a high quality clinical database, of 374,594 admissions to 171 adult critical care units across England, Wales and Northern Ireland from 1995 to 2005. The discrimination and calibration of five risk prediction models, SAPS II, MPM II, APACHE II and III and the ICNARC model plus raw Glasgow Coma Score (GCS) were compared.
There were 11,021 admissions following traumatic brain injury identified (3% of all database admissions). Mortality in ICU was 23.5% and in-hospital was 33.5%. Median ICU and hospital lengths of stay were 3.2 and 24 days, respectively, for survivors and 1.6 and 3 days, respectively, for non-survivors. The ICNARC model, SAPS II and MPM II discriminated best between survivors and non-survivors and were better calibrated than raw GCS, APACHE II and III in 5,393 patients eligible for all models.
Traumatic brain injury requiring intensive care has a high mortality rate. Non-survivors have a short length of ICU and hospital stay. APACHE II and III have poorer calibration and discrimination than SAPS II, MPM II and the ICNARC model in traumatic brain injury; however, no model had perfect calibration.
PMCID: PMC3226136  PMID: 17352796
13.  The relation between the incidence of hypernatremia and mortality in patients with severe traumatic brain injury 
Critical Care  2009;13(4):R110.
The study was aimed at verifying whether the occurrence of hypernatremia during the intensive care unit (ICU) stay increases the risk of death in patients with severe traumatic brain injury (TBI). We performed a retrospective study on a prospectively collected database including all patients consecutively admitted over a 3-year period with a diagnosis of TBI (post-resuscitation Glasgow Coma Score ≤ 8) to a general/neurotrauma ICU of a university hospital, providing critical care services in a catchment area of about 1,200,000 inhabitants.
Demographic, clinical, and ICU laboratory data were prospectively collected; serum sodium was assessed an average of three times per day. Hypernatremia was defined as two daily values of serum sodium above 145 mmol/l. The major outcome was death in the ICU after 14 days. Cox proportional-hazards regression models were used, with time-dependent variates designed to reflect exposure over time during the ICU stay: hypernatremia, desmopressin acetate (DDAVP) administration as a surrogate marker for the presence of central diabetes insipidus, and urinary output. The same models were adjusted for potential confounding factors.
We included in the study 130 TBI patients (mean age 52 years (standard deviation 23); males 74%; median Glasgow Coma Score 3 (range 3 to 8); mean Simplified Acute Physiology Score II 50 (standard deviation 15)); all were mechanically ventilated; 35 (26.9%) died within 14 days after ICU admission. Hypernatremia was detected in 51.5% of the patients and in 15.9% of the 1,103 patient-day ICU follow-up. In most instances hypernatremia was mild (mean 150 mmol/l, interquartile range 148 to 152). The occurrence of hypernatremia was highest (P = 0.003) in patients with suspected central diabetes insipidus (25/130, 19.2%), a condition that was associated with increased severity of brain injury and ICU mortality. After adjustment for the baseline risk, the incidence of hypernatremia over the course of the ICU stay was significantly related with increased mortality (hazard ratio 3.00 (95% confidence interval: 1.34 to 6.51; P = 0.003)). However, DDAVP use modified this relation (P = 0.06), hypernatremia providing no additional prognostic information in the instances of suspected central diabetes insipidus.
Mild hypernatremia is associated with an increased risk of death in patients with severe TBI. In a proportion of the patients the association between hypernatremia and death is accounted for by the presence of central diabetes insipidus.
PMCID: PMC2750153  PMID: 19583864
14.  Pre-injury polypharmacy as a predictor of outcomes in trauma patients 
One of the hallmarks of modern medicine is the improving management of chronic health conditions. Long-term control of chronic disease entails increasing utilization of multiple medications and resultant polypharmacy. The goal of this study is to improve our understanding of the impact of polypharmacy on outcomes in trauma patients 45 years and older.
Materials and Methods:
Patients of age ≥45 years were identified from a Level I trauma center institutional registry. Detailed review of patient records included the following variables: Home medications, comorbid conditions, injury severity score (ISS), Glasgow coma scale (GCS), morbidity, mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, functional outcome measures (FOM), and discharge destination. Polypharmacy was defined by the number of medications: 0–4 (minor), 5–9 (major), or ≥10 (severe). Age- and ISS-adjusted analysis of variance and multivariate analyses were performed for these groups. Comorbidity–polypharmacy score (CPS) was defined as the number of pre-admission medications plus comorbidities. Statistical significance was set at alpha = 0.05.
A total of 323 patients were examined (mean age 62.3 years, 56.1% males, median ISS 9). Study patients were using an average of 4.74 pre-injury medications, with the number of medications per patient increasing from 3.39 for the 45–54 years age group to 5.68 for the 75+ year age group. Age- and ISS-adjusted mortality was similar in the three polypharmacy groups. In multivariate analysis only age and ISS were independently predictive of mortality. Increasing polypharmacy was associated with more comorbidities, lower arrival GCS, more complications, and lower FOM scores for self-feeding and expression-communication. In addition, hospital and ICU LOS were longer for patients with severe polypharmacy. Multivariate analysis shows age, female gender, total number of injuries, number of complications, and CPS are independently associated with discharge to a facility (all, P < 0.02).
Over 40% of trauma patients 45 years and older were receiving 5 or more medications at the time of their injury. Although these patients do not appear to have higher mortality, they are at increased risk for complications, lower functional outcomes, and longer hospital and intensive care stays. CPS may be useful when quantifying the severity of associated comorbid conditions in the context of traumatic injury and warrants further investigation.
PMCID: PMC3249840  PMID: 22229132
Comorbid conditions; outcome prediction; polypharmacy; trauma outcomes
15.  Variation in Cerebral Blood Flow Velocity with Cerebral Perfusion Pressure > 40 mm Hg in 42 Children with Severe Traumatic Brain Injury 
Critical care medicine  2009;37(11):2973-2978.
There is no information regarding the relationship between middle cerebral artery flow velocity (Vmca) and cerebral perfusion pressure in pediatric traumatic brain injury (TBI). We determined the incidence of low, normal and high mean Vmca when CPP is > 40 mm Hg in children with severe TBI.
Prospective observational study
Level 1 pediatric trauma center
42 children < 17 years of age with an admission diagnosis of severe TBI (admission Glasgow Coma Scale [GCS] score < 9), TBI on computed tomography (CT) scan, tracheal intubation/mechanical ventilation and intracranial pressure (ICP) monitoring.
Measurements and Main Results
Bilateral middle cerebral arteries were insonated using transcranial Doppler ultrasonography (TCD) to calculate mean Vmca after TBI. Low mean Vmca was defined as Vmca < 2SD and high was defined as mean Vmca > 2SD. Patients were grouped by age (0.8–2.9, 3–5.9, 6–9.9, and 10–16.9 years) and gender to examine the relationship between CPP and low, high or normal mean Vmca. Potential confounders of the relationship between CPP and mean Vmca (ICP, PaCO2, hematocrit [Hct], sedation, fever and impaired autoregulation were examined). Most (33; 79%) children had normal mean Vmca but 4 (9%) patients had low mean Vmca and 5 children (12%) had high mean Vmca despite CPP > 40 mm Hg. There was no difference in potential confounders of the relationship between CPP and mean Vmca except for Hct, which was lower (25 ± 4 [range 21–30]) in children with high mean Vmca. An inverse relationship between mean Vmca and Hct was also found in boys 10–16.9 years.
Both low and/or high mean Vmca occur with CPP > 40 mm Hg in severe pediatric TBI. Of the potential confounders considered, only lower Hct was associated with high mean Vmca.
PMCID: PMC2766437  PMID: 19770734
cerebral blood flow velocity; cerebral perfusion pressure; pediatric trauma; brain injury; blood pressure; middle cerebral artery flow
16.  Management and outcome of severe head injuries in the Trent region 1985-90. 
Archives of Disease in Childhood  1992;67(12):1430-1435.
In a five year period, 39 children (29 boys, 10 girls) aged 2 months to 13 years (mean 7.8 years) were studied who had suffered a major head injury (29 road traffic accidents, six falls, and four non-accidental injury). The injury had been assessed clinically and by cranial computed tomography or cranial ultrasound (in a single baby of 2 months). Initial Glasgow coma scores for all subjects ranged from 3-11 (mean 5.5), intact survivors 5-11 (7.4), minor handicap 4-11 (6.1), major handicap 3-6 (4.3), fatalities 3-6 (4.1). All were treated with sedation, paralysis, hyperventilation (arterial carbon dioxide tension 3.0-3.5 kPa), intracranial pressure monitoring and moderate body surface hypothermia to 32 degrees C. Nine children died and 30 survived (nine intact, 13 minor disability, and eight major disability). The worst cerebral perfusion pressure was over 40 mm Hg in all but one survivor, and less than 40 mm Hg in seven of nine fatalities. Severe hypocapnia both in the first 24 hours and overall was correlated with poor outcomes (dead or major disability), as were bilateral contusions or diffuse axonal injury.
PMCID: PMC1793983  PMID: 1489220
17.  Improved outcomes from the administration of progesterone for patients with acute severe traumatic brain injury: a randomized controlled trial 
Critical Care  2008;12(2):R61.
Severe traumatic brain injury (TBI) has been increasing with greater incidence of injuries from traffic or sporting accidents. Although there are a number of animal models of TBI using progesterone for head injury, the effects of progesterone on neurologic outcome of acute TBI patients remain unclear. The aim of the present clinical study was to assess the longer-term efficacy of progesterone on the improvement in neurologic outcome of patients with acute severe TBI.
A total of 159 patients who arrived within 8 hours of injury with a Glasgow Coma Score ≤ 8 were enrolled in the study. A prospective, randomized, placebo-controlled trial of progesterone was conducted in the Neurotrauma Center of our teaching hospital. The patients were randomized to receive either progesterone or placebo. The primary endpoint was the Glasgow Outcome Scale score 3 months after brain injury. Secondary efficacy endpoints included the modified Functional Independence Measure score and mortality. In a follow-up protocol at 6 months, the Glasgow Outcome Scale and the modified Functional Independence Measure scores were again determined.
Of the 159 patients randomized, 82 received progesterone and 77 received placebo. The demographic characteristics, the mechanism of injury, and the time of treatment were compared for the two groups. After 3 months and 6 months of treatment, the dichotomized Glasgow Outcome Scale score analysis exhibited more favorable outcomes among the patients who were given progesterone compared with the control individuals (P = 0.034 and P = 0.048, respectively). The modified Functional Independence Measure scores in the progesterone group were higher than those in the placebo group at both 3-month and 6-month follow-up (P < 0.05 and P < 0.01). The mortality rate of the progesterone group was significantly lower than that of the placebo group at 6-month follow-up (P < 0.05). The mean intracranial pressure values 72 hours and 7 days after injury were lower in the progesterone group than in the placebo group, but there was no statistical significance between the two groups (P > 0.05). Instances of complications and adverse events associated with the administration of progesterone were not found.
Our data suggest that acute severe TBI patients with administration of progesterone hold improved neurologic outcomes for up to 6 months. These results provide information important for further large and multicenter clinical trials on progesterone as a promising neuroprotective drug.
Trial Registration
PMCID: PMC2447617  PMID: 18447940
18.  Multiple trauma in children: predicting outcome and long-term results 
Canadian Journal of Surgery  2002;45(2):126-131.
To analyze the management of pediatric trauma and the efficacy of the Pediatric Trauma Score (PTS) in classifying injury severity and predicting prognosis.
A retrospective case series.
The Children’s Hospital of Eastern Ontario, a major pediatric trauma centre.
One hundred and forty-nine traumatized children with 2 or more injuries to 1 body system or a single injury to 2 or more body systems.
Use of the PTS and Glasgow Coma Scale score in trauma management.
Main outcome measures
Types of injuries sustained, complications, missed injuries, psychosocial effects and residual deficiencies.
The average PTS was 8.5 (range from −3 to 11). The total number of injuries sustained was 494, most commonly closed head injury (86). Forty-two percent of children with an average trauma score of 8.5 were treated surgically. There were 13 missed injuries, and complications were encountered in 57 children, the most common being secondary to fractures. Forty-eight (32%) children had residual long-term deficiency, most commonly neurologic deficiency secondary to head injury.
Fractures should be stabilized early to decrease long-term complications. A deficiency of the PTS is the weighting of open fractures of a minor bone. For example, metacarpal fracture is given the same weight as an open fracture of the femur. Neuropsychologic difficulties secondary to trauma are a major sequela of trauma in children.
PMCID: PMC3686935  PMID: 11939656
19.  Childhood motocross truncal injuries: high-velocity, focal force to the chest and abdomen 
BMJ Open  2012;2(6):e001848.
To review the need for operative intervention and critical care services for motocross truncal injuries in children.
Design cohort
Retrospective review of patients identified via the hospital trauma registry.
Our Level 1 Pediatric Trauma Center serves five motocross tracks. These patients require frequent medical care for injuries.
All patients ≤17 years of age with truncal injuries sustained during motocross activities, between 2000 and 2011, were identified through the trauma registry.
Primary and secondary outcome measures
Operative intervention, intensive care unit (ICU) admission, length of stay, morbidity and demographics were reviewed.
Motocross injured 162 children. Thirty (18.5%) were thoracic or abdominal injuries. Operative intervention was required in eight (27%) patients. Mean injury severity score (ISS) was 11.8. ICU admission was required in 50% and average hospital length of stay was 4.1 days. The most common injuries include pulmonary contusion, pneumothorax, spleen and liver lacerations. 13% of subjects suffered truncal injury from motocross on more than one occasion.
Paediatric motocross-related truncal injuries are significant. Surgical intervention is required in 27% of patients. The lower ISS incurred from motocross combined with high surgical and ICU admission rates suggests focal high-impact injuries to the chest and abdomen. Despite significant injury, 13% of motocross patients suffer recurrent injuries. Parents and children need injury prevention education.
PMCID: PMC3533044  PMID: 23166134
20.  Cost factors in Canadian pediatric trauma 
Canadian Journal of Surgery  2001;44(2):117-121.
To estimate the costs of Canadian pediatric trauma and identify cost predictors.
A chart review.
A regional trauma centre.
Study material
The charts of all 221 children who suffered traumatic injuries with an Injury Severity Score (ISS) of 4 or more seen over 6 years at a regional trauma centre.
Main outcome measures
Patient data, injury data, all hospital-based costs, excluding nursing, food and medication costs.
Mean (and standard deviation) patient age was 12.8 (5) years. Sixty percent were boys. Motor vehicle accidents (MVAs) accounted for 71% of the injuries, followed by falls (11%). The mean (and SD) total cost of care was Can$7582 (Can$12 370), and the cost of media was Can$2666. Total cost correlated directly with age (r = 0.29, p < 0.001) and Injury Severity Score (ISS) (r = 0.34, p < 0.001) and inversely with the Pediatric Trauma Score (PTS) (r = −0.20, p = 0.003). The presence of extremity injuries correlated significantly with total cost (r = 0.22, p = 0.001) and PTS (r = −0.25, p < 0.001) but not with the ISS. Logistic regression analysis identified runk injury, ISS and PTS as the main determinants of survival.
The cost of pediatric trauma in Canada can be predicted from admission data and trauma scores. The cost of extremity injuries is significant and can be predicted by the PTS but not the ISS.
PMCID: PMC3695105  PMID: 11308233
21.  Matrix metalloproteinase 9 and cellular fibronectin plasma concentrations are predictors of the composite endpoint of length of stay and death in the intensive care unit after severe traumatic brain injury 
The relationship between severe traumatic brain injury (TBI) and blood levels of matrix metalloproteinase-9 (MMP-9) or cellular fibronectin (c-Fn) has never been reported. In this study, we aimed to assess whether plasma concentrations of MMP-9 and c-Fn could have predictive values for the composite endpoint of intensive care unit (ICU) length of stay (LOS) of survivors and mortality after severe TBI. Secondary outcomes were the state of consciousness measured with the Glasgow Coma Scale (GCS) of survivors at 14 days and Glasgow Outcome Scale Extended (GOSE) at 3 months.
Forty-nine patients with abbreviated injury scores of the head region ≥ 4 were included. Blood was sampled at 6, 12, 24 and 48 hours after injury. MMP-9 and c-Fn concentrations were measured by ELISA. The values of MMP-9 and c-Fn, and, for comparison, the value of the GCS on the field of the accident (fGCS), as predictors of the composite outcome of ICU LOS and death were assessed by logistic regression.
There was a linear relationship between maximal MMP-9 concentration, measured during the 6-12-hour period, and maximal c-Fn concentration, measured during the 24-48-hour period. The risk of staying longer than 9 days in the ICU or of dying was increased in patients with a maximal early MMP-9 concentration ≥ 21.6 ng/ml (OR = 5.0; 95% CI: 1.3 to 18.6; p = 0.02) or with a maximal late c-Fn concentration ≥ 7.7 μg/ml (OR = 5.4; 95% CI: 1.4 to 20.8; p = 0.01). A similar risk association was observed with fGCS ≤8 (OR, 4.4; 95% CI, 1.2-15.8; p = 0.02). No relationship was observed between MMP-9, c-Fn concentrations or fGCS and the GCS at 14 days of survivors and GOSE at 3 months.
Plasma MMP-9 and c-Fn concentrations in the first 48 hours after injury are predictive for the composite endpoint of ICU LOS and death after severe TBI but not for consciousness at 14 days and outcome at 3 months.
PMCID: PMC3570325  PMID: 23249478
Head injury; Prediction; Outcome; Plasmatic biomarker
22.  A Comparison of the Glasgow Coma Scale Score with Full Outline of Unresponsiveness Scale to Predict Patients' Traumatic Brain Injury Outcomes in Intensive Care Units 
Background. Neurological assessment is an essential element of early warning scores used to recognize critically ill patients. We compared the performance of the Glasgow Coma Scale (GCS) with Full Outline of Unresponsiveness (FOUR) scale as an alternative method in the identification of clinically relevant outcomes in traumatic brain injury. Objective. The purpose of this study was to compare the performance of GCS with FOUR scale. Methods. For this study 104 patients with brain injury were recruited from the ICU of Taleghani Hospital, a major teaching hospital in Kermanshah in the western part of Iran. Data was collected concurrently from the ICU admissions by three well-educated nurses and then checked for accuracy by the researcher. Patients were followed up until two weeks or hospital discharge to record their survival status. As a final point expected risk of mortality was calculated using the original formulas for each scale. Results. The mean age of 104 participants was 41.38 ± 18.22 (rang 17 to 86 years) mostly (81 patients 77.9%) males. The FOUR scale has a better prediction for death than GCS. Conclusion. It appears that FOUR scale had better predictive power for mortality and may be a suitable alternative or complementary tool for GCS.
PMCID: PMC4071859
23.  The BRAIN TRIAL: a randomised, placebo controlled trial of a Bradykinin B2 receptor antagonist (Anatibant) in patients with traumatic brain injury 
Trials  2009;10:109.
Cerebral oedema is associated with significant neurological damage in patients with traumatic brain injury. Bradykinin is an inflammatory mediator that may contribute to cerebral oedema by increasing the permeability of the blood-brain barrier. We evaluated the safety and effectiveness of the non-peptide bradykinin B2 receptor antagonist Anatibant in the treatment of patients with traumatic brain injury. During the course of the trial, funding was withdrawn by the sponsor.
Adults with traumatic brain injury and a Glasgow Coma Scale score of 12 or less, who had a CT scan showing an intracranial abnormality consistent with trauma, and were within eight hours of their injury were randomly allocated to low, medium or high dose Anatibant or to placebo. Outcomes were Serious Adverse Events (SAE), mortality 15 days following injury and in-hospital morbidity assessed by the Glasgow Coma Scale (GCS), the Disability Rating Scale (DRS) and a modified version of the Oxford Handicap Scale (HIREOS).
228 patients out of a planned sample size of 400 patients were randomised. The risk of experiencing one or more SAEs was 26.4% (43/163) in the combined Anatibant treated group, compared to 19.3% (11/57) in the placebo group (relative risk = 1.37; 95% CI 0·76 to 2·46). All cause mortality in the Anatibant treated group was 19% and in the placebo group 15.8% (relative risk 1.20, 95% CI 0.61 to 2.36). The mean GCS at discharge was 12.48 in the Anatibant treated group and 13.0 in the placebo group. Mean DRS was 11.18 Anatibant versus 9.73 placebo, and mean HIREOS was 3.94 Anatibant versus 3.54 placebo. The differences between the mean levels for GCS, DRS and HIREOS in the Anatibant and placebo groups, when adjusted for baseline GCS, showed a non-significant trend for worse outcomes in all three measures.
This trial did not reach the planned sample size of 400 patients and consequently, the study power to detect an increase in the risk of serious adverse events was reduced. This trial provides no reliable evidence of benefit or harm and a larger trial would be needed to establish safety and effectiveness.
Trial Registration
This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN23625128.
PMCID: PMC2794266  PMID: 19958521
24.  Chlamydia trachomatis genovar distribution in clinical urogenital specimens from Tunisian patients: high prevalence of C. trachomatis genovar E and mixed infections 
BMC Infectious Diseases  2012;12:333.
This epidemiological study was carried out in Sfax (south of Tunisia) and focused on genital Chlamydia trachomatis (C. trachomatis) genovar distribution.
One hundred and thirty seven genital samples from 4067 patients (4.2%) attending the Habib Bourguiba University hospital of Sfax over 12 years (from 2000 to 2011) were found to be C. trachomatis PCR positive by the Cobas Amplicor system. These samples were genotyped by an in house reverse hybridization method.
One hundred and eight (78.8%) samples contained only one genovar and 29 (21.2%) samples contained two or three genovars. Genovar E was the most prevalent (70.8%) single genovar and it was detected in 90.6% of all the cases. Genovars J, C and L1-L3 were not detected in our samples whereas ocular genovars A and B were in 5 cases. All the five cases were mixed infections. Men had more mixed infections than women (p=0.02) and were more frequently infected by genovars F and K (p<0.05). No associations between current infection, infertility and the genovar distribution were observed. Patients coinfected with Neisseria gonorrhoeae were also significantly more frequently infected with mixed genovars (p=0.04).
In conclusion, we have reported a high prevalence of genovar E and of mixed infections in our study population. Such data could have implications for the control and vaccine development of C. trachomatis in Tunisia.
PMCID: PMC3573954  PMID: 23198910
Chlamydia trachomatis; Genotyping; Reverse hybridization method
25.  Cost factors in pediatric trauma 
Canadian Journal of Surgery  2003;46(6):441-445.
There is a lack of information on the cost of treating trauma in children in developing countries. Therefore, in the pediatric emergency unit of a university hospital in Turkey, we prospectively investigated the cost factors of pediatric trauma and attempted to identify cost predictors.
We prepared questionnaires and charts for 91 children (50 boys, 41 girls) admitted with multiple trauma to obtain data on age, gender, date and mechanism of injury, site of injury, type of the treatment and length of hospital stay. We studied the physical findings, Pediatric Trauma Score (PTS), Revised Trauma Score (RETS) and pediatric Glasgow Coma Scale (GCS) score, and we totalled all hospital-based costs according to Ministry of Health guidelines.
The mean (and standard deviation [SD]) age of the children was 79.4 (52.3) months. Motor vehicle crashes accounted for 45% of the injuries, followed by falls (41%) and bicycle accidents (14%). The mean (and SD) total cost of care was US$376.60 ($428.20) (range from $20–$1995). The cost associated with motor vehicle crashes was higher than that for the other injury types (p < 0.05). Seventeen patients required major and 27 patients required minor surgical treatment, whereas 44 patients were treated conservatively; 3 died. Forty-eight percent of patients were referred from another hospital, and the cost of care of referred patients was significantly higher than for those admitted directly (p < 0.001). The mean (and SD) duration of hospital stay was 98 (150) hours. Total cost correlated directly with the duration of hospital stay and distance of the referred hospital or accident scene from our hospital (p < 0.001, r = 0.827 and 0.374 respectively), but the cost correlated inversely with the PTS, the RETS and the pediatric GCS score (p < 0.001, r = –0.339, –0.301 and –0.453 respectively).
Our findings indicate that the cost of pediatric trauma is high and may be predicted from admission data and trauma scores.
PMCID: PMC3211766  PMID: 14680351

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