DeCuypere Michael, Muhlbauer Michael S, Boop Frederick A, Klimo Paul
Department of Neurosurgery, University of Tennessee Health Science Center;
Semmes-Murphey Neurologic and Spine Institute, and.
J Neurosurg Pediatr. 2016 May;17(5):595-601. doi: 10.3171/2015.7.PEDS15285. Epub 2016 Jan 5.
OBJECTIVE Penetrating brain injury in civilians is much less common than blunt brain injury but is more severe overall. Gunshot wounds (GSWs) cause high morbidity and mortality related to penetrating brain injury; however, there are few reports on the management and outcome of intracranial GSWs in children. The goals of this study were to identify clinical and radiological factors predictive for death in children and to externally validate a recently proposed pediatric prognostic scale. METHODS The authors conducted a retrospective review of penetrating, isolated GSWs sustained in children whose ages ranged from birth to 18 years and who were treated at 2 major metropolitan Level 1 trauma centers from 1996 through 2013. Several standard clinical, laboratory, and radiological factors were analyzed for their ability to predict death in these patients. The authors then applied the St. Louis Scale for Pediatric Gunshot Wounds to the Head, a scoring algorithm that was designed to provide rapid prognostic information for emergency management decisions. The scale's sensitivity, specificity, and positive and negative predictability were determined, with death as the primary outcome. RESULTS Seventy-one children (57 male, 14 female) had a mean age of 14 years (range 19 months to 18 years). Overall mortality among these children was 47.9%, with 81% of survivors attaining a favorable clinical outcome (Glasgow Outcome Scale score ≥ 4). A number of predictors of mortality were identified (all p < 0.05): 1) bilateral fixed pupils; 2) deep nuclear injury; 3) transventricular projectile trajectory; 4) bihemispheric injury; 5) injury to ≥ 3 lobes; 6) systolic blood pressure < 100 mm Hg; 7) anemia (hematocrit < 30%); 8) Glasgow Coma Scale score ≤ 5; and 9) a blood base deficit < -5 mEq/L. Patient age, when converted to a categorical variable (0-9 or 10-18 years), was not predictive. Based on data from the 71 patients in this study, the positive predictive value of the St. Louis scale in predicting death (score ≥ 5) was 78%. CONCLUSIONS This series of pediatric cranial GSWs underscores the importance of the initial clinical exam and CT studies along with adequate resuscitation to make the appropriate management decision(s). Based on our population, the St. Louis Scale seems to be more useful as a predictor of who will survive than who will succumb to their injury.
目的 平民穿透性脑损伤比钝性脑损伤少见得多，但总体上更严重。枪伤（GSWs）导致与穿透性脑损伤相关的高发病率和死亡率；然而，关于儿童颅内枪伤的治疗和预后的报道很少。本研究的目的是确定预测儿童死亡的临床和放射学因素，并对最近提出的儿科预后量表进行外部验证。方法 作者对1996年至2013年在2个主要大城市一级创伤中心接受治疗的年龄从出生到18岁的儿童所遭受的穿透性孤立枪伤进行了回顾性研究。分析了几个标准的临床、实验室和放射学因素预测这些患者死亡的能力。然后作者将圣路易斯儿童头部枪伤量表应用于这些患者，这是一种评分算法，旨在为急诊管理决策提供快速的预后信息。以死亡作为主要结局，确定该量表的敏感性、特异性以及阳性和阴性预测值。结果 71名儿童（57名男性，14名女性）的平均年龄为14岁（范围为19个月至18岁）。这些儿童的总体死亡率为47.9%，81%的幸存者获得了良好的临床结局（格拉斯哥结局量表评分≥4）。确定了一些死亡预测因素（所有p<0.05）：1）双侧固定瞳孔；2）深部核损伤；3）经脑室的弹丸轨迹；4）双侧半球损伤；5）≥3个脑叶损伤；6）收缩压<100 mmHg；7）贫血（血细胞比容<30%）；8）格拉斯哥昏迷量表评分≤5；9）血液碱缺失<-5 mEq/L。将患者年龄转换为分类变量（0 - 9岁或10 - 18岁）后，其不具有预测性。根据本研究中71名患者的数据，圣路易斯量表预测死亡（评分≥5）的阳性预测值为78%。结论 这一系列儿童颅骨枪伤强调了初始临床检查和CT研究以及充分复苏以做出适当管理决策的重要性。基于我们的研究人群，圣路易斯量表似乎作为预测谁能存活比谁会死于损伤更有用。
