Clinical and Physiologic Factors Associated With Mode of Death in Pediatric Severe TBI.

Talia D Baird,Janice A Tijssen,Douglas D Fraser,Saoirse Cameron,Michael R Miller

doi:10.3389/fped.2021.793008

Abstract

Aims and Objectives: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Our aim was to determine the mode of death for children who died with sTBI in a Pediatric Critical Care Unit (PCCU) and evaluate factors associated with mortality.Methods: We performed a retrospective cohort study of all severely injured trauma patients (Injury Severity Score ≥ 12) with sTBI (Glasgow Coma Scale [GCS] ≤ 8 and Maximum Abbreviated Injury Scale ≥ 4) admitted to a Canadian PCCU (2000–2016). We analyzed mode of death, clinical factors, interventions, lab values within 24 h of admission (early) and pre-death (48 h prior to death), and reviewed meeting notes in patients who died in the PCCU.Results: Of 195 included patients with sTBI, 55 (28%) died in the PCCU. Of these, 31 (56%) had a physiologic death (neurologic determination of death or cardiac arrest), while 24 (44%) had withdrawal of life-sustaining therapies (WLST). Median (IQR) times to death were 35.2 (11.8, 86.4) hours in the physiologic group and 79.5 (17.6, 231.3) hours in the WLST group (p = 0.08). The physiologic group had higher partial thromboplastin time (PTT) within 24 h of admission (p = 0.04) and lower albumin prior to death (p = 0.04).Conclusions: Almost half of sTBI deaths in the PCCU were by WLST. There was a trend toward a longer time to death in these patients. We found few early and late (pre-death) factors associated with mode of death, namely higher PTT and lower albumin.

Highlights

Severe traumatic brain injury is the leading cause of pediatric morbidity and mortality in high income countries [1, 2]
There was a trend toward a doubling in pediatric critical care unit (PCCU) length of stay (LOS) in those who died by WLST, and year of study and updates in guidelines were not associated with mode of death
Almost half of sTBI deaths in the PCCU were by WLST; there was a trend toward a longer time to death in these patients

Summary

Introduction

Severe traumatic brain injury (sTBI) is the leading cause of pediatric morbidity and mortality in high income countries [1, 2]. TBIs are responsible for ∼70% of traumatic deaths in the pediatric age group [2]. In pediatric sTBI, outcome prediction is difficult, and outcomes vary between centers [3, 4]. Retrospective cohort studies have explored the association of various factors in sTBI at hospital admission with outcomes [5,6,7,8]. In these studies, mode of death is not reported.

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Conclusion