Objective: The effect of the 2003 severe pediatric traumatic brain injury (TBI) guidelines on outcomes has not been examined. We aimed to develop a set of acute care guideline–influenced clinical indicators of adherence and tested the relationship between these indicators during the first 72 hours after hospital admission and discharge outcomes. Design: Retrospective multicenter cohort study. Setting: Five regional pediatric trauma centers affiliated with academic medical centers. Patients: Children under 18 years with severe traumatic brain injury (admission Glasgow Coma Scale score ≤ 8, International Classification of Diseases, 9th Edition, diagnosis codes of 800.0–801.9, 803.0–804.9, 850.0–854.1, 959.01, 950.1–950.3, 995.55, maximum head abbreviated Injury Severity Score ≥ 3) who received tracheal intubation for at least 48 hours in the ICU between 2007 and 2011 were examined. Interventions: None. Measurements and Main Results: Total percent adherence to the clinical indicators across all treatment locations (prehospital, emergency department, operating room, and ICU) during the first 72 hours after admission to study center were determined. Main outcomes were discharge survival and Glasgow Outcome Scale score. Total adherence rate across all locations and all centers ranged from 68% to 78%. Clinical indicators of adherence were associated with survival (adjusted hazard ratios, 0.94; 95% CI, 0.91–0.96). Three indicators were associated with survival: absence of prehospital hypoxia (adjusted hazard ratios, 0.20; 95% CI, 0.08–0.46), early ICU start of nutrition (adjusted hazard ratios, 0.06; 95% CI, 0.01–0.26), and ICU PaCO₂ more than 30 mm Hg in the absence of radiographic or clinical signs of cerebral herniation (adjusted hazard ratios, 0.22; 95% CI, 0.06–0.8). Clinical indicators of adherence were associated with favorable Glasgow Outcome Scale among survivors (adjusted hazard ratios, 0.99; 95% CI, 0.98–0.99). Three indicators were associated with favorable discharge Glasgow Outcome Scale: all operating room cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.61; 95% CI, 0.58–0.64), all ICU cerebral perfusion pressure more than 40 mm Hg (adjusted relative risk, 0.73; 95% CI, 0.63–0.84), and no surgery (any type; adjusted relative risk, 0.68; 95% CI, 0.53– 0.86). Conclusions: Acute care clinical indicators of adherence to the Pediatric Guidelines were associated with significantly higher discharge survival and improved discharge Glasgow Outcome Scale. Some indicators were protective, regardless of treatment location, suggesting the need for an interdisciplinary approach to the care of children with severe traumatic brain injury .

Objective: The aim of this study was to examine cardiac dysfunction during the first 2 weeks after isolated traumatic brain injury and its association with in-hospital mortality. Design Retrospective. Setting Level 1 regional trauma center. Patients Adult patients with severe traumatic brain injury. Methods: After institutional review board approval, data from adult patients with isolated traumatic brain injury who underwent echocardiography during the first 2 weeks after traumatic brain injury between 2003 and 2010 were examined. Patients with preexisting cardiac disease were excluded. Clinical characteristics and echocardiogram reports were abstracted. Cardiac dysfunction was defined as left ventricular ejection fraction less than 50% or presence of regional wall motion abnormality. Interventions: None. Measurement and Main Results: We examined data from 139 patients with isolated traumatic brain injury who underwent echocardiographic evaluation. Patients were 58 ± 20 years old, 66% were male patients, and 62.6% had subdural hematoma; admission Glasgow Coma Scale score was 3 ± 1 (3–15) and head Abbreviated Injury Scale was 4 ± 1 (2–5). Of this cohort, 22.3% had abnormal echocardiogram: reduced left ventricular ejection fraction was documented in 12% (left ventricular ejection fraction, 43% ± 8%) and 17.5% of patients had a regional wall motion abnormality. Hospital day 1 was the most common day of echocardiographic exam. Abnormal echocardiogram was independently associated with all cause in-hospital mortality (9.6 [2.3–40.2]; p = 0.002). Conclusions: Cardiac dysfunction in the setting of isolated traumatic brain injury occurs and is associated with increased in-hospital mortality. This finding raises the question as to whether there are uncharted opportunities for a more timely recognition of cardiac dysfunction and subsequent optimization of the hemodynamic management of these patients.

There is little information on gender differences in cerebral autoregulation. The purpose of this study was to compare autoregulation of the anterior and posterior circulations using the tilt test method in healthy boys and girls who were 10–16 y of age. Transcranial Doppler was used to measure middle cerebral artery and basilar artery flow velocities (Vmca and Vbas). Cerebral autoregulation (ARI) of the middle cerebral (ARImca) and basilar arteries (ARIbas) was examined using the tilt test method. An ARI <0.4 indicates impaired autoregulation. Among the 13 boys and 13 girls, Vmca and Vbas were higher in girls. All children demonstrated intact autoregulation, but boys had higher ARImca than girls, whereas girls had higher ARIbas than boys. Girls demonstrated greater autoregulation in the basilar artery, whereas boys demonstrated greater autoregulation in the middle cerebral artery. Girls had higher flow velocities in both vessels. This study provides normative data on cerebral autoregulation of the posterior circulation in healthy, awake boys and girls.

The relationship between systolic blood pressure and outcome in children after severe traumatic brain injury (TBI) is unclear. We examined the relationship between age-appropriate systolic blood pressure (AASBP) percentile and outcome after severe pediatric TBI. We examined the association between AASBP percentiles and outcome in 172 children younger than 14 years of age with a Glasgow Coma Scale score < 9. Outcome was evaluated using discharge Glasgow Outcome Scale score. Poor outcome was defined as a Glasgow Outcome Scale score < 4. Poor outcome was associated with AASBP < 75th percentile (odds ratio, 4.2; 95% confidence interval, 2.1-8.3). Patients with systolic blood pressure (SBP) > or = 90 mm Hg and AASBP < 75th percentile had a higher odds for poor outcome compared with patients with SBP > or = 90 mm Hg and AASBP > or = 75th percentile (odds ratio, 3.5; 95% confidence interval, 1.7-7.3). CONCLUSION AASBP < 75th percentile was associated with poor outcome after severe pediatric TBI, even when SBP was > or = 90 mm Hg.