Advancing Predictive Models in Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of disability and mortality among children, causing thousands of deaths each year. Despite tools such as the Glasgow Outcomes Scale (GOS) and the Pediatric Glasgow Coma Scale (PGCS), reliable methods for predicting mortality during initial trauma resuscitation are limited. In a recent study, Katherine Bergus, MD, general surgery resident at The Ohio State University, and Eric Sribnick, MD, PhD, pediatric neurosurgeon and principal investigator in the Center for Clinical and Translational Research at Nationwide Children’s Hospital, aimed to evaluate the association between clinical variables collected from intubated pediatric patients with severe TBI during initial assessment in the trauma bay and in-hospital mortality, providing insights to improve counseling and treatment.

“We saw a real need to address the unanswered questions about mortality in pediatric traumatic brain injury,” says Dr. Sribnick. “While multicenter studies offer more data, our single-center approach brings valuable insights.”

About the Study

The study included 314 pediatric patients aged 0-18, with a median age of 5.5 years. The cohort was predominantly male (66.9%) and white (74.9%), with most injuries resulting from blunt trauma (93.9%). Children under the age of 5 are particularly vulnerable to TBIs, often due to falls and blunt trauma.

Predicting Mortality: Challenges and Findings

Predicting mortality in severe pediatric TBI remains complex due to factors such as:

• Variability in Injury Presentation: Severe TBIs present differently across patients, influenced by factors such as age, injury mechanism, and pre-existing conditions.
• Interrelated Clinical Variables: Variables like the International Normalized Ratio (INR), blood glucose levels, and Glasgow Coma Scale (GCS) scores are interconnected, complicating the isolation of their individual impacts.
• Data Limitations: The retrospective nature of the study posed challenges like missing data and unaccounted patient-specific comorbidities.

Despite these challenges, the study found that elevated INR and blood glucose levels significantly increased mortality risk, while higher GCS scores and platelet counts were linked to better outcomes. The study also highlighted the potential role for newer treatments like Prothrombin Complex Concentrate (PCC) and Tranexamic Acid (TXA) in managing coagulopathy. These treatments have shown promise in quickly reversing coagulopathy, which is critical in reducing the risk of hemorrhage and improving survival outcomes. By stabilizing blood clotting factors, PCC and TXA might offer clinicians additional methods to address one of the challenging complications in pediatric TBI, potentially leading to better overall prognosis for these patients.

Key Findings

• Elevated INR and Blood Glucose: These were associated with increased mortality risk.
• GCS Scores and Platelet Counts: Higher scores were linked to better outcomes.
• Timing of Mortality: Most deaths occurred within the first three days of admission.
• Blunt vs. Penetrating Trauma: Blunt trauma had higher survival rates.
• Neurosurgical Interventions: More common in non-surviving patients, indicating severe cases.

Pioneering Research and Care

The findings pave the way for developing standardized algorithms that integrate critical clinical variables, aiding real-time decision-making during trauma resuscitation. Further research will explore targeted interventions to improve survival rates. Nationwide Children’s remains committed to leading innovations in pediatric trauma care. Peers interested in furthering this work are encouraged to join the team in this mission, enhancing outcomes for children with severe TBI. Dr. Sribnick is looking for collaborators to expand the project.

Reference:

Bergus KC, Patterson KN, Asti L, Bricker J, Beyne TJ, Schulz LN, Schwartz DM, Thakkar RK, Sribnick EA. Association of initial assessment variables and mortality in severe pediatric traumatic brain injury. World J Pediatr Surg. 2024;7(2):e000718. Published 2024 May 28.

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