Defenestration in children younger than 6 years old: mortality predictors in severe head trauma

Child s Nervous System (Impact Factor: 1.16). 09/2009; 25(9):1077-1083. DOI: 10.1007/s00381-009-0924-5

ABSTRACT PurposeThis study aims to describe the characteristics of severe head injuries in children less than 6years old, victims of falls
from windows, and identify the main predictive factors of mortality in this population.

Patients and methodsA cross-sectional study was designed through data derived from medical records of less than 6-year-old children victims of
falls from windows presenting with a severe head injury defined by an initial Glasgow coma scale (GCS) ≤8, hospitalized at
a Pediatric Trauma center level III, between January 2000 and December 2005. Statistical analysis used univariate analysis
and multiple logistic regressions.

ResultsWe identified 58 severe head injuries in children victims of falls from windows. The mean age was 2.8 ± 1.4years, with a
male prevalence (64%); 48% of patients had a GCS ≤5; 62.1% had a Pediatric Trauma Score (PTS) ≤3 at hospital admission. The
mortality rate was 41% (24/58) and most of them (88%; 21/24) died within 48h. An increased death rate was noted in children
admitted with hypoxemia (p = 0.001), low systolic blood pressure (p = 0.002), hypothermia (p = 0.0001), GCS ≤5 (p = 10−5), PTS ≤3 (p = 0.008), hyperglycemia (p = 0.023), coagulation disorders (p = 0.02), and initial intracranial pressure ≥20mmHg (p = 0.03). Initial hypothermia, hyperglycemia, and coagulation disorders were the only independent predictive factors of mortality.

ConclusionSevere head injuries resulting from falls from windows carry a high risk of mortality in less than 6-year-old children. Hypothermia,
hyperglycemia, and coagulation’s disorders are independent predictive factors of mortality. Early deaths could be considered
as direct consequences of uncontrollable brain lesions.

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    ABSTRACT: Object Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center. Methods In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker-Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study. Results One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days-23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%. Conclusions The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.
    Journal of Neurosurgery Pediatrics 02/2014; DOI:10.3171/2014.1.PEDS13393 · 1.63 Impact Factor
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    ABSTRACT: Trauma remains the leading cause of morbidity and mortality in the United States among children from the age 1 year to 21 years old. The most common cause of lethality in pediatric trauma is traumatic brain injury (TBI). Early coagulopathy has been commonly observed after severe trauma and is usually associated with severe hemorrhage and/or traumatic brain injury. In contrast to adult patients, massive bleeding is less common after pediatric trauma. The classical drivers of trauma-induced coagulopathy (TIC) include hypothermia, acidosis, hemodilution and consumption of coagulation factors secondary to local activation of the coagulation system following severe traumatic injury. Furthermore, there is also recent evidence for a distinct mechanism of TIC that involves the activation of the anticoagulant protein C pathway. Whether this new mechanism of posttraumatic coagulopathy plays a role in children is still unknown. The goal of this review is to summarize the current knowledge on the incidence and potential mechanisms of coagulopathy after pediatric trauma and the role of rapid diagnostic tests for early identification of coagulopathy. Finally, we discuss different options for treating coagulopathy after severe pediatric trauma.
    Shock (Augusta, Ga.) 02/2014; 41(6). DOI:10.1097/SHK.0000000000000151 · 2.87 Impact Factor
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    ABSTRACT: RESUMO O trauma craniencefálico (TCE) continua sendo um dos principais responsáveis pelas elevadas taxas de morte e sequelas em suas vítimas. No Brasil, apesar do número crescente de crianças e adolescentes vítimas de TCE, existem poucos estudos sobre o tema. As agressões físicas, as quedas e os acidentes com meios de transporte se destacam como as principais causas de TCE. O atendimento e manejo pré-hospitalar e hospitalar devem ser baseados em protocolos estandardizados, e rigorosamente seguidos. A tomografia do crânio (TC) é o exame de escolha para definição e diagnóstico de lesões agudas decorrentes do TCE, sendo que a escolha quanto ao tratamento (conduta expectante ou cirúrgica), vai depender do quadro clínico e achados na TC. Concernente à letalidade, pode atingir valores altíssimos em vitimas de TCE grave, sendo superior nas vitimas de trauma craniano por abuso. Palavras-chave: Traumatismos craniocerebrais; Mortalidade da criança; Prevençao de acidentes; Neurocirurgia; tratamento de emergência. ABSTRACT Traumatic brain injury (TBI) remains a major contributor to the high rates of death and disabilities. In Brazil, despite the growing number of children and adolescents victims of TBI, few studies exist on the subject. Physical violence (including non abusive head trauma), home acidentes (as falls) and accidents of public roads stand out as the main causes of TBI. The pre-hospital and hospital management should be based on established and standardized protocols that must be followed strictly. The CT-scan is the imaging method of choice for the definition and diagnosis of acute injuries resulting from head trauma. The treatment (surgical or non surgical management), will depend on the clinical exam and CT-scan findings. Concerning mortality, can reach very high values in victims of severe TBI, being higher in victims of abusive head trauma.


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May 27, 2014