Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury

Nikki Miller Ferguson, Ajit Sarnaik, Darryl Miles, Nadeem Shafi, Mark J Peters, Edward Truemper, Monica S Vavilala, Michael J Bell, Stephen R Wisniewski, James F Luther, Adam L Hartman, Patrick M Kochanek, Investigators of the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury (ADAPT) Trial, Shruti Agrawal, Sarah Mahoney, Deepak Gupta, John Beca, Laura Loftis, Kevin Morris, Lauren Piper, Anthony Slater, Karen Walson, Tellen Bennett, Todd Kilbaugh, Am Iqbal O'Meara, Nathan Dean, Ranjit S Chima, Katherine Biagas, Enno Wildschut, Mark Peters, Kerri LaRovere, Joan Balcells, Courtney Robertson, Shira Gertz, Akash Deep, Sian Cooper, Mark Wainwright, Sarah Murphy, John Kuluz, Warwick Butt, Nicole O'Brien, Neal Thomas, Sandra Buttram, Simon Erickson, J Mahil Samuel, Rachel Agbeko, Richard Edwards, Kesava Ananth Ramakrishnan, Margaret Winkler, Santiago Borasino, Joanne Natale, Christopher Giza, Mary Hilfiker, David Shellington, Anthony Figaji, Elizabeth Newell, Edward Truemper, Robert Clark, Kit Newth, Nadeem Shafi, Darryl Miles, Michelle Schober, Jerry Zimmerman, Peter Ferrazzano, Jose Pineda, Ajit Sarnaik, Nikki Miller Ferguson, Ajit Sarnaik, Darryl Miles, Nadeem Shafi, Mark J Peters, Edward Truemper, Monica S Vavilala, Michael J Bell, Stephen R Wisniewski, James F Luther, Adam L Hartman, Patrick M Kochanek, Investigators of the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury (ADAPT) Trial, Shruti Agrawal, Sarah Mahoney, Deepak Gupta, John Beca, Laura Loftis, Kevin Morris, Lauren Piper, Anthony Slater, Karen Walson, Tellen Bennett, Todd Kilbaugh, Am Iqbal O'Meara, Nathan Dean, Ranjit S Chima, Katherine Biagas, Enno Wildschut, Mark Peters, Kerri LaRovere, Joan Balcells, Courtney Robertson, Shira Gertz, Akash Deep, Sian Cooper, Mark Wainwright, Sarah Murphy, John Kuluz, Warwick Butt, Nicole O'Brien, Neal Thomas, Sandra Buttram, Simon Erickson, J Mahil Samuel, Rachel Agbeko, Richard Edwards, Kesava Ananth Ramakrishnan, Margaret Winkler, Santiago Borasino, Joanne Natale, Christopher Giza, Mary Hilfiker, David Shellington, Anthony Figaji, Elizabeth Newell, Edward Truemper, Robert Clark, Kit Newth, Nadeem Shafi, Darryl Miles, Michelle Schober, Jerry Zimmerman, Peter Ferrazzano, Jose Pineda, Ajit Sarnaik

Abstract

Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms.

Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design.

Setting: PICUs in tertiary children's hospitals in United States and abroad.

Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring).

Interventions: None.

Measurements and main results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%).

Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Conflict of interest statement

Dr. Luther disclosed that he does not have any potential conflicts of interest.

References

    1. Coronado VG, Xu L, Basavaraju SV, et al. Surveillance for traumatic brain injury-related deaths--United States, 1997–2007. MMWR Surveill Summ. 2011;60(5):1–32.
    1. Mehta A, Kochanek PM, Tyler-Kabara E, et al. Relationship of intracranial pressure and cerebral perfusion pressure with outcome in young children after severe traumatic brain injury. Dev Neurosci. 2010;32(5–6):413–419.
    1. Keenan HT, Runyan DK, Marshall SW, et al. A population-based study of inflicted traumatic brain injury in young children. JAMA. 2003;290(5):621–626.
    1. Xiang J, Shi J, Wheeler KK, et al. Paediatric patients with abusive head trauma treated in US Emergency Departments, 2006–2009. Brain Inj. 2013;27(13–14):1555–1561.
    1. Duval J, Braun CM, Montour-Proulx I, et al. Brain lesions and IQ: recovery versus decline depends on age of onset. J Child Neurol. 2008;23(6):663–668.
    1. Kriel RL, Krach LE, Panser LA. Closed head injury: comparison of children younger and older than 6 years of age. Pediatr Neurol. 1989;5(5):296–300.
    1. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2012;13(Suppl 1):S1–S82.
    1. Geddes JF, Vowles GH, Hackshaw AK, et al. Neuropathology of inflicted head injury in children. II. Microscopic brain injury in infants. Brain. 2001;124(Pt 7):1299–1306.
    1. Matschke J, Buttner A, Bergmann M, et al. Encephalopathy and death in infants with abusive head trauma is due to hypoxic-ischemic injury following local brain trauma to vital brainstem centers. Int J Legal Med. 2015;129(1):105–114.
    1. Geddes JF, Hackshaw AK, Vowles GH, et al. Neuropathology of inflicted head injury in children. I. Patterns of brain damage. Brain. 2001;124(Pt 7):1290–1298.
    1. Makaroff KL, Putnam FW. Outcomes of infants and children with inflicted traumatic brain injury. Dev Med Child Neurol. 2003;45(7):497–502.
    1. Keenan HT, Runyan DK, Nocera M. Child outcomes and family characteristics 1 year after severe inflicted or noninflicted traumatic brain injury. Pediatrics. 2006;117(2):317–324.
    1. Keenan HT, Runyan DK, Marshall SW, et al. A population-based comparison of clinical and outcome characteristics of young children with serious inflicted and noninflicted traumatic brain injury. Pediatrics. 2004;114(3):633–639.
    1. Lind K, Toure H, Brugel D, et al. Extended follow-up of neurological, cognitive, behavioral and academic outcomes after severe abusive head trauma. Child Abuse Negl. 2016:358–367.
    1. Shein SL, Bell MJ, Kochanek PM, et al. Risk factors for mortality in children with abusive head trauma. J Pediatr. 2012;161(4):716–722. e711.
    1. Peterson C, Xu L, Florence C, et al. Annual Cost of U.S. Hospital Visits for Pediatric Abusive Head Trauma. Child Maltreat. 2015;20(3):162–169.
    1. Miller TR, Steinbeigle R, Wicks A, et al. Disability-adjusted life-year burden of abusive head trauma at ages 0–4. Pediatrics. 2014;134(6):e1545–e1550.
    1. Peterson C, Xu L, Florence C, et al. The medical cost of abusive head trauma in the United States. Pediatrics. 2014;134(1):91–99.
    1. Hymel KP, Makoroff KL, Laskey AL, et al. Mechanisms, clinical presentations, injuries, and outcomes from inflicted versus noninflicted head trauma during infancy: results of a prospective, multicentered, comparative study. Pediatrics. 2007;119(5):922–929.
    1. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics. 1998;102(2 Pt 1):300–307.
    1. Kemp AM, Stoodley N, Cobley C, et al. Apnoea and brain swelling in non-accidental head injury. Arch Dis Child. 2003;88(6):472–476. discussion 472-476.
    1. Scavarda D, Gabaudan C, Ughetto F, et al. Initial predictive factors of outcome in severe non-accidental head trauma in children. Childs Nerv Syst. 2010;26(11):1555–1561.
    1. Parks S, Sugerman D, Xu L, et al. Characteristics of non-fatal abusive head trauma among children in the USA, 2003--2008: application of the CDC operational case definition to national hospital inpatient data. Inj Prev. 2012;18(6):392–398.
    1. Parks SE, Kegler SR, Annest JL, et al. Characteristics of fatal abusive head trauma among children in the USA, 2003–2007: an application of the CDC operational case definition to national vital statistics data. Inj Prev. 2012;18(3):193–199.
    1. Davies FC, Coats TJ, Fisher R, et al. A profile of suspected child abuse as a subgroup of major trauma patients. Emerg Med J. 2015;32(12):921–925.
    1. Deans KJ, Minneci PC, Lowell W, et al. Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma. J Trauma Acute Care Surg. 2013;75(1):157–160.
    1. Piteau SJ, Ward MG, Barrowman NJ, et al. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012;130(2):315–323.
    1. Kesler H, Dias MS, Shaffer M, et al. Demographics of abusive head trauma in the Commonwealth of Pennsylvania. J Neurosurg Pediatr. 2008;1(5):351–356.
    1. Keenan HT. Practical aspects of conducting a prospective statewide incidence study: the incidence of serious inflicted traumatic brain injury in North Carolina. Am J Prev Med. 2008;34(4 Suppl):S120–S125.
    1. Nuno M, Pelissier L, Varshneya K, et al. Outcomes and factors associated with infant abusive head trauma in the US. J Neurosurg Pediatr. 2015:1–8.
    1. Diaz-Olavarrieta C, Garcia-Pina CA, Loredo-Abdala A, et al. Abusive head trauma at a tertiary care children's hospital in Mexico City. A preliminary study. Child Abuse Negl. 2011;35(11):915–923.
    1. Armstead WM, Kiessling JW, Kofke WA, et al. SNP improves cerebral hemodynamics during normotension but fails to prevent sex dependent impaired cerebral autoregulation during hypotension after brain injury. Brain research. 2010;1330:142–150.
    1. Du L, Bayir H, Lai Y, et al. Innate gender-based proclivity in response to cytotoxicity and programmed cell death pathway. The Journal of biological chemistry. 2004;279(37):38563–38570.
    1. Siriussawakul A, Sharma D, Sookplung P, et al. Gender differences in cerebrovascular reactivity to carbon dioxide during sevoflurane anesthesia in children: preliminary findings. Paediatric anaesthesia. 2011;21(2):141–147.
    1. Greiner MV, Greiner HM, Care MM, et al. Adding Insult to Injury: Nonconvulsive Seizures in Abusive Head Trauma. J Child Neurol. 2015;30(13):1778–1784.
    1. Bechtel K, Stoessel K, Leventhal JM, et al. Characteristics that distinguish accidental from abusive injury in hospitalized young children with head trauma. Pediatrics. 2004;114(1):165–168.
    1. Liesemer K, Bratton SL, Zebrack CM, et al. Early post-traumatic seizures in moderate to severe pediatric traumatic brain injury: rates, risk factors, and clinical features. Journal of neurotrauma. 2011;28(5):755–762.
    1. Johnson DL, Boal D, Baule R. Role of apnea in nonaccidental head injury. Pediatr Neurosurg. 1995;23(6):305–310.
    1. Acker SN, Partrick DA, Ross JT, et al. Head injury and unclear mechanism of injury: initial hematocrit less than 30 is predictive of abusive head trauma in young children. J Pediatr Surg. 2014;49(2):338–340.
    1. Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics. 2016;138(1)
    1. Goldstein B, Kelly MM, Bruton D, et al. Inflicted versus accidental head injury in critically injured children. Crit Care Med. 1993;21(9):1328–1332.
    1. Adamo MA, Drazin D, Smith C, et al. Comparison of accidental and nonaccidental traumatic brain injuries in infants and toddlers: demographics, neurosurgical interventions, and outcomes. J Neurosurg Pediatr. 2009;4(5):414–419.
    1. Chang DC, Knight V, Ziegfeld S, et al. The tip of the iceberg for child abuse: the critical roles of the pediatric trauma service and its registry. J Trauma. 2004;57(6):1189–1198. discussion 1198.
    1. Bennett TD, Riva-Cambrin J, Keenan HT, et al. Variation in intracranial pressure monitoring and outcomes in pediatric traumatic brain injury. Arch Pediatr Adolesc Med. 2012;166(7):641–647.
    1. Miller Ferguson N, Shein SL, Kochanek PM, et al. Intracranial Hypertension and Cerebral Hypoperfusion in Children With Severe Traumatic Brain Injury: Thresholds and Burden in Accidental and Abusive Insults. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. 2016;17(5):444–450.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir