Age and Mortality in Pediatric Severe Traumatic Brain Injury: Results from an International Study

Ajit Sarnaik, Nikki Miller Ferguson, A M Iqbal O'Meara, Shruti Agrawal, Akash Deep, Sandra Buttram, Michael J Bell, Stephen R Wisniewski, James F Luther, Adam L Hartman, Monica S Vavilala, Investigators of the ADAPT Trial, Shruti Agrawal, Sarah Mahoney, Deepak Gupta, John Beca, Laura Loftis, Kevin Morris, Lauren Piper, Anthony Slater, Karen Walson, Tellen Bennett, Todd Kilbaugh, A M 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, Peter Ferrazzano, Jose Pineda, Ajit Sarnaik, Ajit Sarnaik, Nikki Miller Ferguson, A M Iqbal O'Meara, Shruti Agrawal, Akash Deep, Sandra Buttram, Michael J Bell, Stephen R Wisniewski, James F Luther, Adam L Hartman, Monica S Vavilala, Investigators of the ADAPT Trial, Shruti Agrawal, Sarah Mahoney, Deepak Gupta, John Beca, Laura Loftis, Kevin Morris, Lauren Piper, Anthony Slater, Karen Walson, Tellen Bennett, Todd Kilbaugh, A M 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, Peter Ferrazzano, Jose Pineda, Ajit Sarnaik

Abstract

Background: Although small series have suggested that younger age is associated with less favorable outcome after severe traumatic brain injury (TBI), confounders and biases have limited our understanding of this relationship. We hypothesized that there would be an association between age and mortality in children within an ongoing observational, cohort study.

Methods: The first 200 subjects from the Approaches and Decisions for Acute Pediatric TBI trial were eligible for this analysis (inclusion criteria: severe TBI (Glasgow Coma Scale [GCS] score ≤ 8], age 18 years, and intracranial pressure (ICP) monitor placed; exclusion: pregnancy). Children with suspected abusive head trauma (AHT) were excluded to avoid bias related to the association between AHT and mortality. Demographics, and prehospital and resuscitation events were collected/analyzed, and children were stratified based on age at time of injury (< 5, 5-< 11, 11-18 years) and presented as mean ± standard error of the mean (SEM). Analyses of variance were used to test the equality of the means across the group for continuous variable, and Chi-square tests were used to compare percentages for discrete variables (post hoc comparisons were made using t test and Bonferroni corrections, as needed). Kaplan-Meier curves were generated for each age subgroup describing the time of death, and log-rank was used to compare the curves. Cox proportional hazards regression models were used to assess the effect of age on time to death while controlling for covariates.

Results: In the final cohort (n = 155, 45 excluded for AHT), overall age was 9.2 years ± 0.4 and GCS was 5.3 ± 0.1. Mortality was similar between strata (14.0, 20.0, 20.9%, respectively, p = 0.58). Motor vehicle accidents were the most common mechanism across all strata, while falls tended to be more common in the youngest stratum (p = 0.08). The youngest stratum demonstrated increased incidence of spontaneous hypothermia at presentation and decreased hemoglobin concentrations and coagulopathies, while the oldest demonstrated lower platelet counts.

Conclusions: In contrast to previous reports, we failed to detect mortality differences across age strata in children with severe TBI. We have discerned novel associations between age and various markers of injury-unrelated to AHT-that may lead to testable hypotheses in the future.

Keywords: Age; Comparative effectiveness research; Pediatric neurocritical care; Pediatric traumatic brain injury; Secondary injuries.

Conflict of interest statement

The authors report no conflicts of interest.

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