The impact of initial management on the outcome of children with severe head injury

Background: Neurotrauma is one of the most important causes of death in the pediatric age group. Head injury is responsible for both primary and secondary brain damage. The outcome of children with brain injury depends on the nature of the primary damage and on how well secondary brain damage can be limited. Appropriate critical care management at the scene and in hospital can prevent secondary brain damage that would otherwise result from cerebral reactions. Hypoxia and hypotension are major early complications of aggravation of secondary brain damage that are amenable to emergency maneuvers at the scene. In the literature, the influence of initial critical care management and early complications on the outcome of children with severe head injury is not clearly documented. Methods and results: We have prospectively examined the impact of the management at the scene on outcome in 40 children admitted to our Pediatric Intensive Care Unit with severe head injury (Glasgow Coma Scale ≤8). The outcome of these children was assessed using the Glasgow Outcome Score (GOS). The results were evaluated by univariate and multivariate analysis. In our series the length of time before admission to an intensive care unit appears to have influenced the outcome among survivors, while the severity of injury is the only factor statistically associated with early complications (hypoxia and hypotension). With regard to the impact of early complications on outcome, the multivariate analysis showed that hypoxia and hypotension were significantly associated with GOS, independently of the GCS. Conclusion: Our results confirm the need for a precise treatment strategy for the initial management of children with neurotrauma to decrease the incidence of secondary brain damage attributable to hypoxia and hypotension.