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Prehospital and emergency management of pediatric traumatic brain injury: a multicenter site survey

Gawin Mai, Jan Hau Lee, Paula Caporal, Juan D. Roa G., Sebastián González-Dambrauskas, Yanan Zhu, Adriana Yock-Corrales, Qalab Abbas, Yasser Kazzaz, Dianna Sri Dewi, Shu-Ling Chong, on behalf of PACCMAN and LARed, Deborah M. Turina, Jesús A. Domínguez-Rojas, Francisco J. Pilar-Orive, Chin Seng Gan, Qalab Abbas, Willmer E. Diaz Villalobos, Ivan J. Ardila, Rujipat Samransamruajkit, Adriana Yock-Corrales, Marisol Fonseca, Gabriela Aparicio, Juan C. Jaramillo-Bustamante, Pei-Chuen Lee, Thelma E. Teran, Nicolas Monteverde-Fernandez, María Miñambres Rodríguez, Juan D. Roa G, Chunfeng Liu, Tao Zhang, Meixiu Ming, Hongxing Dang, Hiroshi Kurosawa, Freddy Israel Pantoja Chamorro, Deiby Lasso Noguera, Esteban Cerón, Natalia Gómez Arriola, and Ruben Eduardo Lasso Palomino

OBJECTIVE

There is a paucity of information on pediatric traumatic brain injury (TBI) care in Asia and Latin America. In this study, the authors aimed to describe the clinical practices of emergency departments (EDs) participating in the Saline in Asia and Latin-America Neurotrauma in the Young (SALTY) study, by comparing designated trauma centers (DTCs) and nontrauma centers (NTCs) in their networks.

METHODS

The authors performed a site survey study on pediatric TBI management in the EDs in 14 countries. Two European centers joined other participating sites in Asia and Latin America. Questions were formulated after a critical review of current TBI guidelines and published surveys. The authors performed a descriptive analysis and stratified centers based on DTC status.

RESULTS

Of 24 responding centers (70.6%), 50.0% were DTCs, 70.8% had academic affiliations, and all centers were in urban settings. Patients were predominantly transferred to DTCs by centralized prehospital services compared to those sent to NTCs (83.3% vs 41.7%, p = 0.035). More NTCs received a majority of their patients directly from the trauma scene compared to DTCs (66.7% vs 25.0%, p = 0.041). Ten centers (41.7%) reported the use of a TBI management guideline, and 15 (62.5%) implemented CT protocols. Ten DTCs reported implementation of intervention strategies for suspected raised intracranial pressure (ICP) before conducting a CT scan, and 6 NTCs also followed this practice (83.3% vs 50.0%, p = 0.083). ED management for children with TBI was comparable between DTCs and NTCs in the following aspects: neuroimaging, airway management, ICP monitoring, fluid resuscitation, anticoagulant therapy, and serum glucose control. Hyperventilation therapy for raised ICP was used by 33.3% of sites.

CONCLUSIONS

This study evaluated pediatric TBI management and infrastructure among 24 centers. Limited differences in prehospital care and ED management for pediatric patients with TBI were observed between DTCs and NTCs. Both DTCs and NTCs showed variation in the implementation of current TBI management guidelines. There is an urgent need to investigate specific barriers to guideline implementation in these regions.

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Low-field magnetic resonance imaging in a boy with intracranial bolt after severe traumatic brain injury: illustrative case

Awais Abbas, Kiran Hilal, Aniqa Abdul Rasool, Ume-Farwah Zahidi, Muhammad Shahzad Shamim, and Qalab Abbas

BACKGROUND

Conventional magnetic resonance imaging (cMRI) is sensitive to motion and ferromagnetic material, leading to suboptimal images and image artifacts. In many patients with neurological injuries, an intracranial bolt (ICB) is placed for monitoring intracranial pressure (ICP). Repeated imaging (computed tomography [CT] or cMRI) is frequently required to guide management. A low-field (0.064-T) portable magnetic resonance imaging (pMRI) machine may provide images in situations that were previously considered contraindications for cMRI.

OBSERVATIONS

A 10-year-old boy with severe traumatic brain injury was admitted to the pediatric intensive care unit, and an ICB was placed. Initial head CT showed a left-sided intraparenchymal hemorrhage with intraventricular dissection and cerebral edema with mass effect. Repeated imaging was required to assess the brain structure because of continually fluctuating ICP. Transferring the patient to the radiology suite was risky because of his critical condition and the presence of an ICB; hence, pMRI was performed at the bedside. Images obtained were of excellent quality without any ICB artifact, guiding the decision to continue to manage the patient conservatively. The child later improved and was discharged from the hospital.

LESSONS

pMRI can be used to obtain excellent images at the bedside in patients with an ICB, providing useful information for better management of patients with neurological injuries.

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Differences in clinical outcomes and resource utilization in pediatric traumatic brain injury between countries of different sociodemographic indices

Keith Wei Han Liang, Jan Hau Lee, Syeda K. Qadri, Janani Nadarajan, Paula Caporal, Juan D. Roa G, Sebastián González-Dambrauskas, Qalab Abbas, Yasser Kazzaz, and Shu-Ling Chong

OBJECTIVE

The burden of traumatic brain injury (TBI) is disproportionately high in low- and middle-income countries (LMICs). This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe TBIs between LMICs and non-LMICs in Asia and Latin America.

METHODS

The authors performed an observational multicenter study from January 2014 to February 2023 among children with moderate to severe TBIs admitted to participating pediatric intensive care units (PICUs) in the Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network). They classified sites according to their 2019 sociodemographic index (SDI). Low, low-middle, and middle SDI sites were considered LMICs, while high-middle and high SDI sites were considered non-LMICs. The authors documented patient demographics and TBI management. Accounting for death, they recorded 14-day PICU-free and 28-day hospital-free days, with fewer free days indicating poorer outcome. The authors compared children who died and those who had poor functional outcomes (defined as Pediatric Cerebral Performance Category [PCPC] level of moderate disability, severe disability, or vegetative state or coma) between LMICs and non-LMICs and performed a multivariable logistic regression analysis for predicting poor functional outcomes.

RESULTS

In total, 771 children with TBIs were analyzed. Mortality was comparable between LMICs and non-LMICs (9.6% vs 12.9%, p = 0.146). Children with TBIs from LMICs were more likely to have a poor PCPC outcome (31.0% vs 21.3%, p = 0.004) and had fewer ICU-free days (median [IQR] 6 [0–10] days vs 8 [0–11] days, p = 0.004) and hospital-free days (median [IQR] 9 [0–18] days vs 13 [0–20] days, p = 0.007). Poor functional outcomes were associated with LMIC status (adjusted OR [aOR] 1.53, 95% CI 1.04–2.26), a lower Glasgow Coma Scale score (aOR 0.83, 95% CI 0.78–0.88), and the presence of multiple trauma (aOR 1.49, 95% CI 1.01–2.19). Children with TBIs in LMICs required greater resource utilization in the form of early intubation and mechanical ventilation (81.6% vs 73.2%, p = 0.006), use of hyperosmolar therapy (77.7% vs 63.6%, p < 0.001), and use of antiepileptic drugs (73.9% vs 53.1%, p < 0.001).

CONCLUSIONS

Within Asia and Latin America, children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. Further research should focus on investigating causal factors and developing targeted interventions to mitigate these disparities.