Sociodemographic characteristics
There were 4258 pediatric emergency room(ER) visits and TBI contributed to 7.4% (317) of ER visits in one year study period. A total of 317 study subjects were included, 96% response rate. From 317 study subjects, there were 218(68.8%) males and 99 (31.2%) females with male to female ratio of 2.2:1. The study subjects aged from 7 months to 14 years; mean age of 7.66 + 3.82 years. School age groups, 5 -10 years and adolescents, 10-14 years contributed for 36.9% (117) and 36.3%(115) of TBI. One hundred eighty three (57.7%) of study subjects came from southern nations, nationalities and peoples regional state (SNNPR) while the rest 134(42.3%) came from the neighboring Oromia and Somali Ethiopian regional states (See Table 1).
Boys were predominantly affected and they accounted for 65.8%, 68.3% and 71.3% of TBI in under-fives, school age and adolescent age groups respectively.
Pattern and mechanism of traumatic brain injury
TBI were caused mainly by RTA (road traffic accidents), 144 (45.4%) cases. Out of these, majority were pedestrians, 120 (83.3%) while 25 (17.3%) were occupants in vehicles. The other TBI causes were falls, 104 (32.8%); fighting/violence, 40 (12.6%); animal bite or kick injury, 28 (8.8%) and one case of assault (child maltreatment). Most preschool falls occurred at home 29 (60.7%) while 94.1% (32) of school age and 97.6% (41) of adolescent falls happened outdoor. Eighty three (79.8%) of falls and 84 (58.3%) of road traffic accidents occurred in boys (See figure 1).
Concerning timing of presentation, most of study subjects presented within 24 hours of injury, 258 (81.4%). Thirty one (9.8%) and 28(8.8%) of TBI cases presented between 24hours and 72hours, and after 72 hours of injury (See table 2).
Most injuries were unintentional injuries, 87.4% (277). Almost all of intentional injuries, 38 (97.5%) were due to fighting with only one case of child maltreatment. Eight nine (28%) of TBI cases had lost consciousness at the time of presentation. From study subjects, 26(8.2%) exhibited seizure, 40(12.6%) had pupillary abnormality sign and 60(18.9%) showed sign of increased intracranial pressure (ICP). Hypertension and depressed mentation were the most common manifestation of increased ICP, each accounting for 22(6.9%) of increased ICP cases. Vomiting 16(5%) was the other common increased ICP feature (See table 2).
Most pediatric TBI cases were conscious at the time of presentation, 195 (61.5%) had GCS of 15/15. The least GCS was 3 in 4 cases and mean GCS at admission was 13.4 + 2.7. Up on grading of TBI severity, mild TBI was the commonest type, 231(72.9%) with moderate TBI and severe TBI contributing for 61(19.2%) and 25(7.9%) of study subjects. Mild TBI was caused by all mechanisms of injury while moderate and severe injuries were mainly caused by RTA and fall in 96.7% (59) and 100% (25) of cases. Hypotension and hyperglycemia on presentation were documented in 9 (2.8%) and 20 (6.3%) of TBI cases (See table 2).
Skull X-ray was done in 177 (55.8%) of study subjects and skull fractures were found in 100(31.5%) TBI cases: linear skull fractures, 27 (8.5%); depressed skull fractures, 72 (22.7%); basal skull fracture, 1(0.3%). Head CT scan was done in 70.7% (224) of TBI cases and intracranial hematomas, 6% (14): 3 epidural, 6 subdural, 4 intracerebral and 1 subarachnoid hemorrhage were documented. Other head CT findings were cerebral contusion and diffuse axonal injury in 30 (13.4%); simple skull fractures without intracranial bleeding in 94 (41.9%), and depressed skull fractures with contusion or intracranial bleeding in 36 (16%) of cases. Head CT scan was normal in 50 (15.8%) of TBI. Head CT findings in fatal cases were depressed skull fractures with extensive intracerebral hemorrhages in 4 (40%), diffuse axonal injury (DAI) in 4 (40%).Head CT was not done in 2 cases (10%) (See table 2).
Associated extracranial injuries were reported in 256 (80.7%) of TBI. From these, soft tissue injury is the commonest form, 179 (56.5%) followed by extremity bone fracture 70(22.1%), chest or abdominal injury 6 (1.9%) and one case of vertebral bone injury (See table 3).
Management and outcome
One hundred twenty nine (72.2%) of TBI were managed conservatively while 88(27.8%) underwent various surgical operations within the first 01 week of presentation. Most operated cases aged 5 to 10 years, 48 /88 (55%). None of the operated patient died. The surgical indications for operations were evacuation of epidural and subdural hematoma in 4 (4.5%); wound debridement for compound skull fracture in 19 (21.3%) and depressed skull fracture elevation in 66 (74.2%) (See table 3).
Regarding duration of hospitalization, majority of TBI cases stayed from 4 to 7days, 34% (108) while 78(24.6%) were discharged with in 24hours of arrival. Prolonged hospitalization (≥ 1month) was seen in 2 patients with severe TBI and extremity fracture with extensive soft tissue injury. The average hospitalization days for cases who died was 4.5 days (median 2 days), and 5/ 10(50%) of deaths occurred within the first 3days of admission (See table 4).
Concerning outcome at discharge, 303(95.6%) study subjects recovered from the injury: 267(84.2%) with good recovery without neurologic deficit, 30(9.5%) with focal neurologic deficit and 10(3.2%) with depressed mentation. Ten (3.2%) deaths were documented and 2 cases were referred to another hospital and 2 went against medical advice (See table 3)
Factors affecting outcome
On bivariate analysis factors significantly associated with outcome of pediatric TBI with 95% CI and p value < 0.05 were: comorbid illness, loss of consciousness and convulsion at presentation, increased ICP sign, severity of head injury, presence of hypotension, hyperglycemia on presentation, and head CT scan findings.
On multivariable logistic regression, presence of increased ICP at admission was associated with 1.4 times increased chances of death, [AOR: 1.415 (95% CI: 0.458-9.557)]. Severe TBI was associated with double risk of death compared with moderate and mild TBI, [AOR: 2.103 (95% CI: 0.965-4.524)]. Presence of hyperglycemia [AOR: 2.318 (95% CI: 0.873-7.874)] and CT scan finding of contusion, DAI or intracranial bleeding [AOR: 2.45 (95% CI: 0.811-7.952)] were also found to be significantly associated with outcome of pediatric TBI (See table 4).