Trimble Duncan J, Parker Samantha L, Zhu Liang, Cox Charles S, Kitagawa Ryan S, Fletcher Stephen A, Sandberg David I, Shah Manish N
Department of Neurosurgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, USA.
Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Children's Memorial Hermann Hospital, Houston, TX, USA.
Childs Nerv Syst. 2020 Nov;36(11):2657-2665. doi: 10.1007/s00381-020-04637-z. Epub 2020 May 6.
This study aims to assess outcomes of pediatric patients with blunt traumatic brain injury (TBI) with a presenting Glasgow Coma Score (GCS) of 3.
After local institutional review board approval, we identified patients ages 0 to15 years with blunt TBI and a reported GCS of 3 between 2007 and 2017 from a pediatric level 1 trauma center prospective registry. Exclusion criteria were cardiac death on arrival and penetrating injury. We recorded clinical variables from patients with a non-pharmacologic GCS of 3 and pupillary exam documented by a neurosurgical attending or resident. The original Glasgow Outcome Scale (GOS) was used to compare with other studies. Importance of variables to survival was calculated.
A total of 88 patients (mean age 6.9 years) were included with a mortality rate of 68%. Twelve percent had a poor long-term outcome (GOS 2 or 3) while 20% had a good long-term outcome (GOS 4 or 5). Median follow-up was 1.8 years. Initial group comparison revealed patients in group 1 (survivors) had less hypotension on arrival (14% SBP < 90 mmHg vs. 66%, p < 0.0001), higher temperatures on arrival (36.3 °C vs 34.9 °C, p = 0.0002), lower ISS (29.7 vs 39.5, p = 0.003), less serious injury to other major organs (34% vs 61%, p = 0.02), more epidural hematomas (24% vs 7%, p = 0.04), and less evidence of brain ischemia on CT (7% vs 39%, p = 0.002) or brainstem infarct, hemorrhage, or herniation (0% vs 27%, p = 0.002). Differences between the 2 groups in age, sex, race, MOI, AIS score, presence of midline shift > 5 mm, or time from injury to hospital arrival or time to surgery were not statistically significant. Classification tree analysis showed that the most important variable for survival was pupillary exam; mortality was 92% in presence of bilateral, fixed dilated pupils. The relative importance of initial temperature, MOI, and hypotension to survivability was 0.79, 0.75, and 0.47, respectively.
Twenty percent of our pediatric non-pharmacologic GCS 3 cohort had a good functional outcome. Lack of bilaterally fixed and dilated pupils was the most important factor for survival. Temperature, MOI, and hypotension also correlated with survival. The data support selective aggressive management for these patients.
本研究旨在评估格拉斯哥昏迷评分（GCS）为3分的小儿钝性颅脑损伤（TBI）患者的预后情况。
经当地机构审查委员会批准，我们从一家儿科一级创伤中心前瞻性登记处确定了2007年至2017年间年龄在0至15岁、钝性TBI且报告GCS为3分的患者。排除标准为入院时心源性死亡和穿透伤。我们记录了非药物性GCS为3分且经神经外科主治医生或住院医生记录瞳孔检查情况的患者的临床变量。使用原始格拉斯哥预后量表（GOS）与其他研究进行比较。计算变量对生存的重要性。
共纳入88例患者（平均年龄6.9岁），死亡率为68%。12%的患者长期预后不良（GOS 2或3），而20%的患者长期预后良好（GOS 4或5）。中位随访时间为1.8年。初始组间比较显示，第1组（幸存者）患者入院时低血压情况较少（收缩压<90 mmHg者占14%，而另一组为66%，p<0.0001），入院时体温较高（36.3℃对34.9℃，p = 0.0002），损伤严重程度评分（ISS）较低（29.7对39.5，p = 0.003），其他主要器官损伤较轻（34%对61%，p = 0.02），硬膜外血肿较多（24%对7%，p = 0.04），CT显示脑缺血证据较少（7%对39%，p = 0.002）或脑干梗死、出血或疝形成较少（0%对27%，p = 0.002）。两组在年龄、性别、种族、损伤机制（MOI）、简明损伤定级（AIS）评分、中线移位>5 mm、受伤至入院时间或手术时间方面的差异无统计学意义。分类树分析表明，生存的最重要变量是瞳孔检查；双侧固定散大瞳孔时死亡率为92%。初始体温、MOI和低血压对生存能力的相对重要性分别为0.79、0.75和0.47。
我们的小儿非药物性GCS 3分组中，20%的患者功能预后良好。双侧无固定散大瞳孔是生存的最重要因素。体温、MOI和低血压也与生存相关。这些数据支持对这些患者进行选择性积极治疗。
