Study Center
This study was a retrospective chart review that was conducted at the Jim Pattison Children’s Hospital (JPCH) in Saskatoon, Canada.
Population and criteria
Eligible individuals were identified through medical records and a Pediatric Intensive Care Unit (PICU) registry. Inclusion criteria included: patients ≤ 18 years, severe TBI defined as Glasgow Coma Scale (GCS) score of ≤ 8 prior to triage in the JPCH ED, injury from 2010 to time of ethics approval, Head Abbreviated Injury Scale (AIS) score of ≥ 3, TBI ICD codes (800-801.9, 803-804.9, 850-854.1, or 959.01) and triaged in the ED. Increased intracranial pressure (ICP) at the ED was defined by i) craniotomy with 12 hours of admission; or, ii) herniation syndrome or midline shift > 5 mm on neuroimaging; or, iii) raised ICP monitoring of > 20 mm cm H2O within 12 hours of admission. Exclusion criteria included death prior to arrival of ED.
Emergency Department Metrics
An exhaustive list of potential management indicators was created by a pediatric neurointensivist and neurosurgeon with experience in traumatic brain injury. Indicators and metrics were considered if they were consistent with TBI guidelines, clinically relevant, and accessible through a retrospective chart review. It was then vetted through a focus group which comprised of 3 pediatric intensivists, two neurosurgeons, and four emergency physicians. Modifications to the list ensued, followed by a final focus group review. Items required a 75% majority to be included.
The final metrics included: a) position of head of bed (HOB); b) position of head (C-spine precaution); c) time of first temperature check; d) temperature treated in 30 minutes if <36 or >37.5°C; e) hypoxia treated in 30 minutes after onset; f) systemic hypotension [SBP < 70 + 2 (age) or MAP < 40 + 1.5 (age)] treated within 30 minutes of admission; g) blood gas CO2 obtained within 15 minutes of admission; h) ETCO2 monitoring; i) blood gas CO2 corrected within 5 minutes if <35 or >40; j) clinical seizures treated within 10 minutes of onset; k) timing of admission to labs including glucose, CBC, differential and electrolytes; l) timing of admission to computed tomography (CT); m) complications in CT (i.e. herniation, unplanned extubation); n) personnel with patient in CT; o) indications to administer hyperosmolar therapy; and, p) timing of admission to either neurosurgical operating room or PICU.
Variables
Patient identifiers included age, weight, gender, and mechanism of injury (including motor vehicular collision, fall, pedestrian vs. vehicle, gunshot, assault, bicycle). Pre-trauma center metrics included time of injury to arrival at trauma center, distance of scene to trauma center (if beyond urban emergency medical services catchment), and mode of transport (ground, fixed wing, helicopter EMS). Injury severity was documented with Head AIS and Pediatric Risk of Mortality (PRISM) score. Raised ICP at trauma center was defined as craniotomy within 12 hours of admission, raised ICP > 20 cm H2O within one hour of placement, and ED neuroimaging suggesting herniation syndrome or midline shift > 5 mm). ED TBI metrics were discussed above. Outcomes included: day 1 mortality, mortality, comfort care at admission, length of PICU stay, length of hospital stay, and GOS scores of survivors.
Statistical Methods
All analyses were be done using SPSS software. Discrete variables were reported as percentages, and continuous variables were reported as median and interquartile ranges.