title: The role of serious concomitant injuries in the treatment and outcome of pediatric severe traumatic brain injury.
abstract: BACKGROUND
  The study objective was to describe the epidemiology of serious concomitant injuries and their effects on outcome in pediatric severe traumatic brain injury (sTBI).
  
  
  METHODS
  A retrospective cohort of all severely injured (Injury Severity Score [ISS] ≥ 12) pediatric patients (<18 years) admitted to our pediatric intensive care unit, between 2000 and 2011, after experiencing an sTBI (Glasgow Coma Scale [GCS] score ≤ 8 and head Abbreviated Injury Scale [AIS] ≥ 4) were included. Two groups were compared based on the presence of serious concomitant injuries (maximum AIS score ≥ 3). Multivariate logistic regression was undertaken to determine variable associations with mortality.
  
  
  RESULTS
  Of the 180 patients with sTBI, 113 (63%) sustained serious concomitant injuries. Chest was the most commonly injured extracranial body region (84%), with lung being the most often injured. Patients with serious concomitant injuries had increased age, weight, and injury severity (p < 0.001) and were more likely injured in a motor vehicle collision (91% vs. 48%, p < 0.001). Those with serious concomitant injuries had worse sTBI, based on lower presedation GCS (p = 0.031), higher frequency of fixed pupils (p = 0.006), and increased imaging abnormalities (SAH and DAI, p ≤ 0.01). Non-neurosurgical operations and blood transfusions were more frequent in the serious concomitant injury group (p < 0.01). The differences in mortality for the two groups failed to reach statistical significant (p = 0.053), but patients with serious concomitant injuries had higher rates of infection and acute central diabetes insipidus, fewer ventilator-free days, and greater length of stays (p < 0.05). Multivariate analyses revealed fixed pupillary response (odd ratio [OR], 63.58; p < 0.001), presedation motor GCS (OR, 0.23; p = 0.001), blood transfusion (OR, 5.80; p = 0.008), and hypotension (OR, 4.82; p = 0.025) were associated with mortality, but serious concomitant injuries was not (p = 0.283).
  
  
  CONCLUSIONS
  Head injury is the most important prognostic factor in mortality for sTBI pediatric patients, but the presence of serious concomitant injuries does contribute to greater morbidity, including longer stays, more infections, fewer ventilator-free days, and a higher level of care required on discharge from hospital.
  
  
  METHODS
  Prognostic and epidemiologic study, level III.
authors.affiliation: From the Departments of Surgery (T.C.S.), Pediatrics (D.D.F.), Physiology and Pharmacology (D.D.F.), and Clinical Neurological Sciences (D.D.F.), Western University; Trauma Program (T.C.S.), London Health Sciences Center; Translational Research Centre (D.D.F.); Children's Health Research Institute (D.D.F.); and Centre for Critical Illness Research (D.D.F.), London, Ontario, Canada; and Department of Pediatric Critical Care (I.M.A.), King Fahad Medical City, Riyadh, Saudi Arabia.
authors.forename: Tanya Charyk
authors.initials: TC
authors.lastname: Stewart
authors.forename: Ibrahim M
authors.initials: IM
authors.lastname: Alharfi
authors.forename: Douglas D
authors.initials: DD
authors.lastname: Fraser
mesh_terms: D000293:Adolescent; D001930:Brain Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D002648:Child; D002675:Child, Preschool; D003952:Diagnostic Imaging / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009104:Multiple Trauma / Q000453:epidemiology*; D009864:Ontario / Q000453:epidemiology; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D015599:Trauma Severity Indices