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

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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.

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Acknowledgments

Research reported in this publication was supported by the National Institute of Neurological Disorders and Stroke of the National Institutes of Health under Award Number U01 NS081041. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Investigators for the ADAPT trial are Shruti Agrawal, Addenbrookes Hospital, Cambridge, UK; Sarah Mahoney, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK; Deepak Gupta, All India Institute of Medical Sciences, New Delhi, India; John Beca, Auckland DHB Charitable Trust, Starship Children’s Hospital, Auckland, NZ; Laura Loftis, Baylor College of Medicine, Houston, TX; Kevin Morris, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK; Lauren Piper, Levine Children’s Hospital, Charlotte, NC; Anthony Slater, Children’s Health Queensland Hospital and Health Service, Brisbane, Australia; Karen Walson, Children’s Healthcare of Atlanta, Atlanta, GA; Tellen Bennett, Children’s Hospital Colorado, Aurora, CO; Todd Kilbaugh, Children’s Hospital of Philadelphia, Philadelphia, PA; AM Iqbal O’Meara, Children’s Hospital of Richmond, Richmond, VA; Nathan Dean, Children’s National Medical Center, Washington, DC; Ranjit S. Chima, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Katherine Biagas, Columbia University, New York, NY; Enno Wildschut, Erasmus Medical Center, Rotterdam, Netherlands; Mark Peters, Great Ormond St Hospital NHS Foundation Trust, London, UK; Kerri LaRovere, Boston Children’s Hospital, Boston, MA; Joan Balcells, Hospital Vall d’Hebron, Barcelona, Spain; Courtney Robertson, John Hopkins University, Baltimore, MD; Shira Gertz, Joseph M. Sanzari Children’s Hospital at Hackensack University Medical Center, Hackensack, NJ; Akash Deep, King’s College Hospital NHS Foundation Trust, London, UK; Sian Cooper, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Mark Wainwright, Lurie Children’s Hospital, Chicago IL; Sarah Murphy, Massachusetts General Hospital, Boston, MA; John Kuluz, Miami Children’s Hospital, Miami, FL; Warwick Butt, Murdoch Children’s Research Institute, Royal Children’s Hospital, Melbourne, Australia; Nicole O’Brien, Nationwide Children’s Hospital, Columbus, OH; Neal Thomas, Pennsylvania State University, Hershey, PA; Sandra Buttram, Phoenix Children’s Hospital, Phoenix, AZ; Simon Erickson, Princess Margaret Hospital, Perth, Australia; J. Mahil Samuel, Royal Manchester Children’s Hospital NHS Foundation Trust, Manchester, UK; Rachel Agbeko, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK; Richard Edwards, University Hospital Bristol NHS Foundation Trust, Bristol, UK; Kesava Ananth Ramakrishnan, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Margaret Winkler and Santiago Borasino, University of Alabama at Birmingham, Birmingham, AL; Joanne Natale, University of California, Davis, Sacramento, CA; Christopher Giza, University of California, Los Angeles, Los Angeles, CA; Mary Hilfiker and David Shellington, University of California, San Diego, San Diego, CA; Anthony Figaji, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa; Elizabeth Newell, University of Iowa Children’s Hospital, Iowa City, IA; Edward Truemper, University of Nebraska Medical Center and Nebraska Medical Center, Omaha, NE; Robert Clark, University of Pittsburgh, Pittsburgh, PA; Kit Newth, Children’s Hospital of Los Angeles, Los Angeles, CA; Nadeem Shafi, LeBonheur Children’s Hospital, Memphis, TN; Darryl Miles, University of Texas Southwestern Medical Center, Dallas, TX; Michelle Schober, University of Utah, Jerry Zimmerman, University of Washington, Seattle, WA; Peter Ferrazzano, University of Wisconsin, Madison, WI; Jose Pineda, Washington University–St. Louis, St. Louis, MO; and Ajit Sarnaik, Wayne State University, Detroit, MI.

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Authors and Affiliations

  1. Departments of Pediatrics, Wayne State University, Detroit, MI, USA

    Ajit Sarnaik

  2. Departments of Pediatrics, Virginia Commonwealth University, Richmond, VA, USA

    Nikki Miller Ferguson & AM Iqbal O’Meara

  3. Departments of Pediatrics, Addenbrookes Hospital, Cambridge, UK

    Shruti Agrawal

  4. Departments of Pediatrics, Kings College Hospital, London, UK

    Akash Deep

  5. Departments of Pediatrics, Phoenix Children’s Hospital, Phoenix, AZ, USA

    Sandra Buttram

  6. Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh, 3434 Fifth Avenue, Pittsburgh, PA, 15260, USA

    Michael J. Bell

  7. Departments of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA

    Stephen R. Wisniewski & James F. Luther

  8. Departments of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA

    Monica S. Vavilala

  9. The Office of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA

    Adam L. Hartman

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  1. Ajit Sarnaik
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Consortia

For the 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

Corresponding author

Correspondence to Michael J. Bell.

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The authors report no conflicts of interest.

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Sarnaik, A., Ferguson, N.M., O’Meara, A.I. et al. Age and Mortality in Pediatric Severe Traumatic Brain Injury: Results from an International Study. Neurocrit Care 28, 302–313 (2018). https://doi.org/10.1007/s12028-017-0480-x

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  • DOI: https://doi.org/10.1007/s12028-017-0480-x

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