Early Resuscitation of Children With Moderate-to-Severe Traumatic Brain Injury

OBJECTIVES: Traumatic brain injury is a leading cause of death and disability in children. Guidelines have been established to prevent secondary brain injury caused by hypotension or hypoxia. The purpose of this study was to identify the prevalence, monitoring, and treatment of hypotension and hypoxia during "early" (prehospital and emergency department) care and to evaluate their relationship to vital status and neurologic outcomes at hospital discharge. METHODS: This was a retrospective study of 299 children with moderate-to-severe traumatic brain injury presenting to a level 1 pediatric trauma center. We recorded vital signs and medical provider response to hypotension and/or hypoxia during all portions of early care. RESULTS: Blood pressure (31%) and oxygenation (34%) were not recorded during some portion of "early care." Documented hypotension occurred in 118 children (39%). An attempt to treat documented hypotension was made in 48% (57 of 118 children). After adjusting for severity of illness, children who did not receive an attempt to treat hypotension had an increased odds of death of 3.4 and were 3.7 times more likely to suffer disability compared with treated hypotensive children. Documented hypoxia occurred in 131 children (44%). An attempt to treat hypoxia was made in 92% (121 of 131 children). Untreated hypoxia was not significantly associated with death or disability, except in the setting of hypotension. CONCLUSIONS: Hypotension and hypoxia are common events in pediatric traumatic brain injury. Approximately one third of children are not properly monitored in the early phases of their management. Attempts to treat hypotension and hypoxia significantly improved outcomes. Pediatrics 2009;124:56-64