Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury

Nikki Miller Ferguson, Ajit Sarnaik, Darryl Miles, Nadeem Shafi, Mark J. Peters, Edward Truemper, Monica S. Vavilala, Michael J. Bell, Stephen R. Wisniewski, James F. Luther, Adam L. Hartman, Patrick M. Kochanek

Research output: Contribution to journalArticle

Abstract

Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial - a comparative effectiveness study using an observational, cohort study design. Setting: PICUs in tertiary children's hospitals in United States and abroad. Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). Interventions: None. Measurements and Main Results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Original languageEnglish (US)
Pages (from-to)1398-1407
Number of pages10
JournalCritical Care Medicine
Volume45
Issue number8
DOIs
StatePublished - Aug 1 2017
Externally publishedYes

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Craniocerebral Trauma
Mortality
Intracranial Pressure
Traumatic Brain Injury
Resuscitation
Wounds and Injuries
Seizures
Glasgow Coma Scale
Intracranial Hypertension
Apnea
Tertiary Care Centers
Observational Studies
Cohort Studies

Keywords

  • abusive head injury
  • comparative effectiveness research
  • pediatric neurocritical care
  • pediatric traumatic brain injury
  • secondary injuries

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

Cite this

Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury. / Miller Ferguson, Nikki; Sarnaik, Ajit; Miles, Darryl; Shafi, Nadeem; Peters, Mark J.; Truemper, Edward; Vavilala, Monica S.; Bell, Michael J.; Wisniewski, Stephen R.; Luther, James F.; Hartman, Adam L.; Kochanek, Patrick M.

In: Critical Care Medicine, Vol. 45, No. 8, 01.08.2017, p. 1398-1407.

Research output: Contribution to journalArticle

Miller Ferguson, N, Sarnaik, A, Miles, D, Shafi, N, Peters, MJ, Truemper, E, Vavilala, MS, Bell, MJ, Wisniewski, SR, Luther, JF, Hartman, AL & Kochanek, PM 2017, 'Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury', Critical Care Medicine, vol. 45, no. 8, pp. 1398-1407. https://doi.org/10.1097/CCM.0000000000002378
Miller Ferguson, Nikki ; Sarnaik, Ajit ; Miles, Darryl ; Shafi, Nadeem ; Peters, Mark J. ; Truemper, Edward ; Vavilala, Monica S. ; Bell, Michael J. ; Wisniewski, Stephen R. ; Luther, James F. ; Hartman, Adam L. ; Kochanek, Patrick M. / Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury. In: Critical Care Medicine. 2017 ; Vol. 45, No. 8. pp. 1398-1407.
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abstract = "Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial - a comparative effectiveness study using an observational, cohort study design. Setting: PICUs in tertiary children's hospitals in United States and abroad. Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). Interventions: None. Measurements and Main Results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3{\%} vs 34.8{\%}; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0{\%} vs 33.5{\%}; p < 0.001), 2) have apnea (34.3{\%} vs 12.3{\%}; p = 0.002), and 3) have seizures (28.6{\%} vs 7.7{\%}; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7{\%}; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7{\%} vs nonabusive head trauma, 18.7{\%}; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7{\%} vs nonabusive head trauma, 69.0{\%}). Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.",
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T1 - Abusive head trauma and mortality-an analysis from an international comparative effectiveness study of children with severe traumatic brain injury

AU - Miller Ferguson, Nikki

AU - Sarnaik, Ajit

AU - Miles, Darryl

AU - Shafi, Nadeem

AU - Peters, Mark J.

AU - Truemper, Edward

AU - Vavilala, Monica S.

AU - Bell, Michael J.

AU - Wisniewski, Stephen R.

AU - Luther, James F.

AU - Hartman, Adam L.

AU - Kochanek, Patrick M.

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N2 - Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial - a comparative effectiveness study using an observational, cohort study design. Setting: PICUs in tertiary children's hospitals in United States and abroad. Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). Interventions: None. Measurements and Main Results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

AB - Objectives: Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms. Design: First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial - a comparative effectiveness study using an observational, cohort study design. Setting: PICUs in tertiary children's hospitals in United States and abroad. Patients: Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring). Interventions: None. Measurements and Main Results: Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%). Conclusions: In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

KW - abusive head injury

KW - comparative effectiveness research

KW - pediatric neurocritical care

KW - pediatric traumatic brain injury

KW - secondary injuries

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