Pediatric head injury: The critical role of the emergency physician

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Neurologic injury is a significant source of morbidity and mortality in pediatric patients. In order to clarify the factors influencing outcome in pediatric patients with severe head injury, we studied 200 consecutive patients with Glasgow Coma Scale (GCS) scores of 8 or less. The following data were collected: age, GCS score, presence of mass lesions, oculovestibular reflexes (OVR), pupillary size and reactivity, intracranial pressure (ICP), apnea, presence of hypotension, hypoxia (PO2 less than 60 torr), or hypercarbia (PCO2 greater than or equal to 35 torr), presence of multiple trauma, and Modified Injury Severity Scale (MISS) score. Outcome was assessed by the Glasgow Outcome Scale at a minimum of six months following recovery. Of the 200 patients in the study, 86 (43%) had isolated head injury (IHI) and 114 (57%) had head injury plus multiple trauma (HI + MT). Overall, 26% of patients had mass lesions; 28% had altered OVR; 33% had fixed, dilated pupils; 79% had increased intracranial pressure; and 29% had hypotension, hypoxia, or hypercarbia. Overall mortality was 21.5%. Severity of injury (as judged by presence of mass lesions, GCS, OVR, fixed pupils) was more pronounced in patients with IHI, although increased ICP was more common in patients with HI + MT; however, death was almost three times more common in patients with HI + MT (30% versus 10.5%). In the IHI group, two of nine patients who died (22%) had hypotension, hypoxia, or hypercarbia; all but four patients (88%) in the HI + MT group had hypotension, hypoxia, or hypercarbia.(ABSTRACT TRUNCATED AT 250 WORDS)