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

Article · September 2009with81 Reads
DOI: 10.1007/s00381-009-0924-5
Abstract
Purpose: This study aims to describe the characteristics of severe head injuries in children less than 6 years old, victims of falls from windows, and identify the main predictive factors of mortality in this population. Patients and methods: A 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) < or =8, hospitalized at a Pediatric Trauma center level III, between January 2000 and December 2005. Statistical analysis used univariate analysis and multiple logistic regressions. Results: We identified 58 severe head injuries in children victims of falls from windows. The mean age was 2.8 +/- 1.4 years, with a male prevalence (64%); 48% of patients had a GCS < or =5; 62.1% had a Pediatric Trauma Score (PTS) < or =3 at hospital admission. The mortality rate was 41% (24/58) and most of them (88%; 21/24) died within 48 h. 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 < or =5 (p = 10(-5)), PTS < or =3 (p = 0.008), hyperglycemia (p = 0.023), coagulation disorders (p = 0.02), and initial intracranial pressure > or =20 mmHg (p = 0.03). Initial hypothermia, hyperglycemia, and coagulation disorders were the only independent predictive factors of mortality. Conclusion: Severe 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.
ORIGINAL PAPER
Defenestration in children younger than 6 years old:
mortality predictors in severe head trauma
Jose Roberto Tude Melo &Federico Di Rocco &
Laudenor Pereira Lemos-Júnior &Thomas Roujeau &
Bertrand Thélot &Christian Sainte-Rose &
Philippe Meyer &Michel Zerah
Received: 12 April 2009 / Revised: 10 May 2009 /Published online: 24 June 2009
#Springer-Verlag 2009
Abstract
Purpose This study aims to describe the characteristics of
severe head injuries in children less than 6 years old,
victims of falls from windows, and identify the main
predictive factors of mortality in this population.
Patients and methods A 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.
Results We identified 58 severe head injuries in children
victims of falls from windows. The mean age was 2.8±
1.4 years, 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
48 h. 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 20 mmHg (p=0.03). Initial hypothermia, hyper-
glycemia, and coagulation disorders were the only inde-
pendent predictive factors of mortality.
Conclusion Severe head injuries resulting from falls from
windows carry a high risk of mortality in less than 6-year-
old children. Hypothermia, hyperglycemia, and coagula-
tions disorders are independent predictive factors of
mortality. Early deaths could be considered as direct
consequences of uncontrollable brain lesions.
Keywords Pediatric .Fall .Head injury .Prognosis .
Mortality
Introduction
Head injuries are first-line dominant lesions in more than
80%ofthechildrenwithaseveretrauma[1]. Falls
represent one of the most frequent mechanisms of injuries,
in less than 6-year-old children, and are recognized as a
major public health concern in many countries around the
world [26]. However, with respect to environmental and
socioeconomic conditions specific in various geographical
areas, circumstances of falls resulting in severe head
Childs Nerv Syst (2009) 25:10771083
DOI 10.1007/s00381-009-0924-5
Source of funding: CAPES Brazil (Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior)Exchange Program for Ph.D. studies
with Stage Abroad.
J. R. T. Melo :F. Di Rocco :T. Roujeau :C. Sainte-Rose :
M. Zerah
Department of Pediatric Neurosurgery Hôpital Necker-Enfants
Malades (Assistance Publique Hôpitaux de ParisFrance),
Université Descartes Paris 5,
Paris, France
J. R. T. Melo (*):L. P. Lemos-Júnior
Post-Graduate Program in Medicine and HealthSchool of
Medicine, Federal University of Bahia,
Salvador, Brazil
e-mail: robertotude@gmail.com
B. Thélot
Institut National de Veille Sanitaire,
Paris, France
P. Meyer
Pediatric Surgical Critical Care Unit, and Anesthesiology,
Hôpital Necker-Enfants Malades (Assistance Publique Hôpitaux
de ParisFrance), Université Descartes Paris 5,
Paris, France
injuries can vary considerably [26]. Among these
numerous mechanisms of accidents, accidental falls from
windows in children have been sparsely reported in
Europe, and the real incidence of pediatric head traumas
resulting from this precise accidental mechanism in European
metropolitan areas remains unknown and probably under-
estimated [5,7]. These accidents carry a high risk of
mortality and permanent disability in young children.
The aim of this study was to report our experience of
severe head injuries resulting from falls from windows in
less than 6-year-old children in the Paris area and to try
to verify the predictive value of previously identified
factors of increased mortality, such as hypoxia, arterial
hypotension, hypothermia, hyperglycemia, coagulation
disorders, and intracranial hypertension (ICH), in this
particular population.
Materials and methods
This is a retrospective cross-sectional study based on the
analysis of clinical data of children aged 0 to 6 years
presenting with a severe head trauma defined by an initial
Glasgow Coma Score (GCS) 8. We reviewed the medical
records of children admitted between January 2000 and
December 2005 (6 years), to the emergency room of
Hôpital Necker Enfants Malades (Paris, France) after
prehospital medical management by one of the emergency
medical units of the Service Aide Médicale dUrgence de
Paris (SAMU). Children victims of documented falls from
windows were selected for the study.
Data were collected for age, gender, circumstances and
height of falls, initial GCS and Pediatric Trauma Score
(PTS), clinical presentation, and medical management by
the medical emergency team (SAMU). The results of initial
cranial computed tomography (CCT) scan exploration
included brain and whole-body exploration (WBE) that
was systematically performed. Outcome was measured by
the Glasgow outcome scale upon discharge [8]
Initial clinical and biological data considered as potential
predictive factors of increased mortality were:
&Hypoxemia, defined by a measured arterial oxygen
saturation (SaO
2
) less than 97% in mechanically
ventilated patients [9]
&Hypotension, defined as a systolic arterial blood
pressure (SAP), recorded through an arterial catheter.
Less than normal arterial SAP for the age based on the
American Heart Association criteria [10]
&Elevated blood glucose level and coagulation disorders
during the first 48 h defined as a blood glucose level
11.1 mmol/L (200 mg/dL) [11] and prothrombin time
(PT) <50% [12]
&Accidental hypothermia was considered in children
with a body temperature <35°C upon admission [13]
&Initial intracranial pressure (ICP) in excess of 20 mmHg
was considered as intracranial hypertension [14].
Invasive ICP measurements (parenchymal pressure
transducer) at monitoring insertion and during the first
48 h were recorded and analyzed in all children except
in those with initial GCS=3, without brainstem reflex,
and with severe coagulations disorders, for whom the
surgical risk of transducer insertion was considered too
high. In those patients, ICP was only estimated by
transcranial Doppler (TCD) examination that was
routinely performed upon admission in all children.
TCD profiles were considered abnormal with an end-
diastolic velocity less than 25 cm/s, or pulsatility index
more than 1.31, or backflow, or no-flow evidence [15].
&Patients with GCS 5 and PTS 3 were considered as
the most severely injured according to the literature
[1619]
Statistical analysis was done by using SSPS for
Windows (Statistical Package for Social Sciences). For
data analysis, all quantitative variables were expressed as
mean and standard deviation. Categorical data were
analyzed by using χ
2
test. We considered for the analyses
the 95% confidence interval and statistical significance
when p<0.05. We used the tstudent test to verify
variables with normal distribution and MannWhitney
test for nonnormal distributions variables. A multiple
logistic regression was done to analyze the independent
factors of increased mortality.
This was a cooperative descriptive international study in
agreement with French law requirements (no informed
consent required, anonymous computer data bank analysis)
and approved by the Brazilian Researchs Ethics Committee
under registration no. 06/07.
Results
We evaluated 81 medical files of children less than 6 years
old, victims of falls from height and presenting with a
severe head trauma. Among them, 58 (72%) were victims
of accidental falls from windows. Mean age was of 2.8±
1.4 years. We did not observe any accidental falls from
windows in children younger than 11 months. Accidents
occurred in 43% of the cases in children less than 3 years
old and in 57% in those between 3 and 6 years of age.
When separating the group according to gender, boys
represented 52% in those younger than 3 years and 73%
among children between 3 and 6 years. Epidemiological
characteristics are shown in Table 1. Considering that each
floor corresponds to a 3-m height, 17% of children fell from
1078 Childs Nerv Syst (2009) 25:10771083
3 m, 26% from 6 m, and 38% between 9 and 12 m. In 19%
of cases, the height of the fall was more than 12 m
(Table 1). Prehospital management was carried out by a
physician of one of the regional emergency medical system
teams (SAMU). Systematic peripheral intravenous catheter
insertion, tracheal intubation, and mechanical ventilation after
anesthesia induction were performed according to the French
National Guidelines for emergency management of severe
head injuries in all the cases. According to these recommen-
dations, isotonic saline solutions without glucose addition and
hydroxy-ethyl-amidon for fluid loading were used as needed.
Upon admission, children were managed by a specialized
trauma team as previously described. Hypoxemia was
recorded despite adapted mechanical ventilation in 24% of
the children, and SAP under normal levels was noted in 36%.
Accidental hypothermia was found in ten children. Blood
glucose levels 11.1 mmol/L (200 mg/dL) and PT <50% were
found in 48% and 29% patients, respectively. No intravenous
solutions containing glucose had been authorized before
bloodmeasurementandnochildrenhadapreviously
recognized diabetes mellitus or coagulation disorder history.
In 88% of children, at least one intracranial lesion was
evidenced on initial CCT scan examination, and an initially
suspected intracranial hemorrhage or cerebral swelling was
confirmed on further CCT scan examination in the others.
The most frequent injuries on initial CCT scan were skull
fractures (62%), diffuse brain swelling (47%), and multiple
brain contusions (38%). In 14%, the three injuries were
associated. All but two children had an associated lesion
evidenced on WBE, mainly a chest lesion, pulmonary
contusion, or pleural effusion without rib fracture (83%),
and abdominal, mainly spleen or liver contusion (38%). In
29%, a fracture, mainly in the upper limbs, femoral shaft, or
pelvic ring, was also present.
ICP was measured in 36 children. An initial ICP
20 mmHg was found in only 28% of the patients, but, in
81% of the cases, ICP increased above 20 mmHg during
the first 48 h following trauma. Initial TCD was considered
as abnormal in 65% of the patients. In those patients
without ICP measurement, TCD demonstrated acute intra-
cranial hypertension with dramatically decreased diastolic
velocities or no flow/backflow in all the cases.
The global mortality rate was 41% (24 patients). Death
occurred within the first 48 h after trauma in 21 (88%; 21/24)
children and within the first 24 h in 83% (20/24). The
mortality rate in children between 11 months and 3 years was
44%, compared to 39% in the group of children above 3 years
(p=0.7). Predictive factors of mortality isolated by the
univariate analysis are presented in Table 2. The mortality
rate was increased in hypoxemic children (71% vs 32%
incidence in nonhypoxemic patients, p= 0.001) and in
patients with hypotension (67% vs 27%, p=0.002) and
accidental hypothermia (90% death vs 31%, p=0.0001). If a
formal correlation could not be established when considering
each level of fall (p=0.12), a highly increased mortality rate
was found in children victims of falls in excess of 15 m
(Fig. 1; 72% death rate vs 34%, p=0.03).
Table 1 Epidemiological characteristics of 58 children with severe
head trauma, victims of falls from windows, admitted to the
emergency room of Hôpital Necker Enfants Malades (Paris, France)
from 2000 to 2005
Epidemiological
characteristics
Age group Total, n(%)
02years old,
n(%)
36years old,
n(%)
58 (100)
Gender
Masculine 13 (52) 24 (73) 37 (64)
Feminine 12 (48) 9 (27) 21 (36)
Height of fall
1st floor 7 (28) 3(9) 10 (17)
2nd floor 8 (32) 7 (21) 15 (26)
3rd floor 5 (20) 6 (18) 11 (19)
4th floor 4 (16) 7 (21) 11 (19)
5th floor 1 (4) 10 (31) 11 (19)
Geographic area
Ile de France
a
24 (96) 31 (94) 55 (95)
Region of Paris
b
11 (46) 9 (29) 20 (36)
18ème and 19ème 4 (36) 5 (56) 9 (45)
Others 7 (64) 4 (44) 11 (55)
Out of Ile de France
(province)
1 (4) 2 (6) 3 (5)
a
Region of Ile de France (including Paris, Essonne, Hauts-de-Seine,
Seine-Saint-Denis, Seine-et-Marne, Val-de-Marne, Val-dOise, Yvelines)
b
Region (arrondissements) of Paris where the accidents happened
Table 2 Univariate analysis of statistical significant factors related to
mortality in 58 children between 11 months and 6 years old after a severe
head injury caused by fallsfrom windows, admitted at the Hôpital Necker
Enfants Malades (Paris, France), between January 2000 and December
2005
Variables Survivors
vs dead, %
p
Arterial oxygen saturation <97% 28 vs 72 0.001
Systolic arterial blood hypotension
a
33 vs 67 0.002
Hypothermia (temperature<35°C) 12 vs 88 0.0001
GCS533vs7710
5
PTS3 47 vs 53 0.008
Hyperglycemia (11.1 mmol/L) 32 vs 68 0.023
PT< 50% 35 vs 65 0.02
ICP20 60 vs 40 0.03
GCS Glasgow Coma Score, PTS Pediatric Trauma Score, PT
prothrombin time, ICP intracranial pressure (admission)
a
Values based on the American Heart Association
Childs Nerv Syst (2009) 25:10771083 1079
As expected, an increased mortality was noted in children
with a GCS5(48%vs14%,p=10
5
)andaPTS3(62%vs
23%, p=0.008). Regarding biochemical predictive factors of
mortality, children with a blood glucose level 11.1 mmol/L
(200 mg/dL) had a mortality rate of 68%, compared to a
17% incidence in normoglycemic children (p=0.023), and
those with coagulation disorders had a mortality rate of 65%
compared to 13% (p=0.02).
Initial increased ICP was more determinant for increased
mortality (40% death vs 8% p=0.03) than delayed raised
ICP (17% vs 14% in those with a controlled ICP, p= 0.06).
TCD could be considered as a valuable noninvasive
alternative to ICP measurement in these circumstances
since none of the children with a normal initial examination
died, contrasting with a mortality rate of 31% in those with
abnormal initial TCD profiles (p= 0.06).
In the multiple logistic regressions, we found that only
accidental hypothermia (<35°C; odds ratio (OR)= 0.29;
IC=0.090.91; p= 0.035), hyperglycemia (11.1 mmol/L;
OR=12.77; IC = 1.21134.68; p=0.034), and PT<50%
(OR=13.67; IC =1.26148.47; p=0.031) were indepen-
dent factors related to mortality in the first 48 h after head
trauma (Table 3).Allthreepatientswhodiedafter48hof
admission had sustained a fall of less than 6 m and none of
them was admitted with hypoxia, hypotension, or hypo-
thermia. Two of them presented hyperglycemia and all had
raised ICP in the first 48 h. Two children died after 48 h
but during the first week after trauma and were related to a
septic complications and one at 3 weeks for renal failure.
Discussion
Falls have been clearly identified as one of the most frequent
causes of head injury in children. Among falls, accidental falls
from windows in less than 6-year-old children have been
rarely individualized, especially in European countries [7,20
23]. Analyzing our trauma data bank, we found falls from
windows as the most frequent source of severe head injuries
in young children in the Paris area, representing 72% of the
mechanisms of brain injuriesinthispopulation.The
characteristics regarding the incidence of falls from windows
in specific areas of Paris, as those demographic areas with
high population density and with poorer accommodations
were previously described, and preventive actions were
proposed [5,7].
Behavioral specificities with development of walking
capabilities, need for environment exploration without
perception of dangerous situations, could explain the
specific risks encountered in children between 1 and 3 years
of age. In reports of pediatric trauma [2224], a male
prevalence among victims of head traumas could be found,
beginning at the first year of life [6]. This male predom-
inance was noted in the present study mainly in children
older than 3 years of age.
Falls from windows always represent a high-energy
accident with a combination of complex deceleration forces
and direct impact. This combination of forces is illustrated
in our series by the distribution of brain lesions, with skull
fractures resulting from direct impact with the ground, and
diffuse brain contusions, and their nearly constant associ-
ation with pulmonary contusions without rib fractures,
resulting from deceleration. The severity of the lesions has
been correlated with the height of the fall [21,25]. Multiple
trauma and severe head injuries associated with other life-
threatening lesions have been described in victims of fall
from windows [2527]. The small size of our sample
prevented extensive analysis of various brain lesions as
predictive factors of mortality. We did not found a formal
correlation between the height of the fall and the severity
of the lesions, although a marked increased mortality rate
was found for falls in exceeding 15 m. Elements that
might have decreased the velocity of the fall, like primary
impact on tents, bushes, or tarpaulins or final impact on
soft surfaces like grass or wet ground could be confound-
0
10
20
30
40
50
60
70
80
1st floor (n=10) 2nd floor (n=15) 3rd floor (n=11) 4th floor (n=11) 5th floor and
above (n=11)
Deaths
Fig. 1 Percentage of deaths in defenestrated head-injured children,
between 11 months and 6 years old, according to the level of fall,
admitted at the Hôpital Necker Enfants Malades (Paris, France)
between January 2000 and December 2005 (N=58)
Tab l e 3 Model of multiple logistic regressions of independent
prognostic factors related to death in 58 defenestrate severely head-
injured children, between 11 months and 6 years old, admitted at the
Hôpital Necker Enfants Malades, between January 2000 and Decem-
ber 2005 (Paris, France)
Variables OR (95%CI)
a
p
Hypothermia 0.29 (0.090.91) 0.035
Hyperglycemia 12.77 (1.21134.68) 0.034
PT< 50% 13.67 (1.26148.47) 0.031
PT prothrombin time; OR odds ratio, 95%CI 95% confidence interval
1080 Childs Nerv Syst (2009) 25:10771083
ing for an objective appreciation of the kinetics of the
accident [25].
A mortality rate of 41% was noted in this study. It
represents a much higher death incidence than the one
reported in the general population of head-injured children
at our institution [16]. In a series of 585 severely head-
injured children, a 22% incidence of death was found,
although this incidence could be significantly higher in
children less than 2 years of age [16]. Despite early
aggressive medical management according to French
guidelines on management of head injuries, death occurred
within the first 24 h after trauma in 83% (20/24) of the
cases and was the direct consequence of uncontrollable
brain and chest injuries. Even though GCS and PTS could
be efficient for evaluating the severity of brain and
associated lesions in trauma children [17], they could be
influenced by many other variables and could not be
considered as independent factors predicting outcome.
Rapid development of secondary brain lesions is a major
issue in severe brain injury and must be prevented by
medical management that could decrease the incidence of
secondary cerebral insults of systemic origin like hypoten-
sion, hypoxia, hyperglycemia, and hypercapnia [9,19,28,
29]. In our series, homogenous medical management
including early mechanical ventilation, volume expansion,
and avoidance of glucose perfusion could decrease the bias
created by various medical interventions that has been
encountered in previous reports evaluating the influence of
systemic factors on mortality. Despite early mechanical
ventilation and active volume expansion, 24% of our
patients were still hypoxic upon arrival, and 36% were
hypotensive. Hypoxia doubled and hypotension tripled the
risks of deaths in our series. The deleterious influence of
hypotension and hypoxemia in head-injured patients has
been noted previously [9,10,19,2932]. These risks of
hypotension and hypoxemia could be particularly increased
in patients with severe pulmonary lesions and bleeding
abdominal injuries that are frequently associated with brain
lesions in young children victims of falls from windows.
Accidental hypothermia has been described as a factor of
worsening prognosis in trauma. It could be multifactorial,
related to body exposure to cold environment, peripheral
vessel constriction, and hemorrhagic shock and resulting in
tissue hypoperfusion or dysfunction of autogenic tempera-
ture regulation with brain damage [13,29]. Our analysis
demonstrated that body temperature of <35°C was an
independent factor influencing mortality and underlines
the need for hypothermia prevention within the first
minutes following trauma. Hyperglycemia has also been
described as a predictor of bad outcome in severely ill
patients, especially in those with head trauma [16,3337].
We found an increased rate of mortality in children with
blood glucose levels 11.1 mmol/L (200 mg/dL), and
hyperglycemia was an independent factor related to
mortality. There is no clinical consensus on the level of
blood glucose that should be considered as harmful and on
the real benefits of actively treating head-injured children
[3339]; however, exclusion of exogenous glucose uptake
by exclusive normal saline intravenous infusion should be
the rule within the first 24 h. Coagulation disorders have
been previously recognized as predictor of bad outcome
and are described in most severe head trauma with
extensive brain tissue destruction [40,41]. This correlation
was confirmed in our study and PT <50% was an
independent predictive factor of mortality.
Intracranial hypertension was described in the literature
as an important predictive factor of outcome in severe head
injuries [14,18,4244]. In the present study, an initial ICP
in excess of 20 mmHg was associated with increased
mortality but was not an independent factor of increased
mortality. The fact that ICP was not invasively recorded in
most patients with a GCS of 3 and absent brain stem reflex
could be a major source of bias. Delayed increased ICP
within the first 48 h was not related to increased mortality,
but the small size of the sample could prevent efficient
analysis. TCD was used in all the patients upon arrival to
the hospital. This noninvasive and highly reproductive
method could be used as a valuable alternative to ICP
monitoring on an emergency bedside basis. A trend toward
a significant correlation between abnormal TCD profiles
and increased mortality could be noted in our patients. This
value of initial TCD in evaluating cerebral blood flow and
predicting indirectly increased ICP and bad outcome has
been previously described in children with severe head
injuries [15,19].
The high mortality rate observed within the first 48 h in
our population reflects the severity of the lesions resulting
from falls from windows in young children. Delayed deaths
resulted from infectious complications and multiple organ
failure but not directly from uncontrollable raised ICP.
These findings illustrate the need for developing dedicated
programs of prevention based on parental education in
high-risk populations and reinforcement of window security
adapted to young children. Prevention of accidents could be
the only efficient means to decrease this unacceptably high
trauma mortality in young children.
Conclusion
Falls from windows are the main causes of severe head
injuries and result in traumatic death in less than 6-year-
oldchildrenintheParisarea.Itcarriesaveryhighrisk
of early mortality related to uncontrollable brain injuries
and severe associated chest and abdominal lesions. Body
temperature <35°C, blood glucose levels 11.1 mmol/L
Childs Nerv Syst (2009) 25:10771083 1081
(200 mg/dL), and PT <50% are independent prognostic
factors of mortality. Prevention of secondary brain
injuries of systemic origin such as hypoxemia, hypoten-
sion, hypothermia, and hyperglycemia is mandatory to
improve outcome and must be initiated as soon as
possible. However, reduction of early mortality relies
mainly on primary prevention of accidents.
Without conflict of interest
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