SEVERE HEAD-INJURY IN CHILDREN - ANALYZING THE BETTER OUTCOME OVER A DECADE AND THE ROLE OF MAJOR IMPROVEMENTS IN INTENSIVE-CARE

We suggest a few possible explanations, including improvement of inten sive care, as the main cause, for the improved outcome after severe he ad injury in children and present the predictors of outcome observed i n a contemporary series. From January 1984 to June 1988 we saw 117 chi ldren (ages 0-14) with postresuscitation GCS (Glasgow Come Scale) scor es of 3-8. The more recent cohort of children seen in 1994-1996 vias m ade up of 152 patients. Apart from standard statistics we used a segme ntation method called CHAID (SSPS software). Previously known predicto rs of outcome are found still to apply in our series. Although in the recent period there was a lower proportion of patients with GCS 3-4(11 % versus 32%), a higher percentage had suffered multiple trauma (56% v ersus 33%). The rates. of craniotomy and of ICP monitoring were simila r (66% and 61%). Comparison of the two cohorts for outcome at discharg e and through 1 year shows that mortality fell from 33% to 10% and the proportion achieving improvement of neurological status increased fro m 24% to 56%. CHAID analysis showed that the mortality rates of patien ts within specific groups declined significantly over the two periods: (1) a significant reduction in mortality was seen in patients with GC S 5-7, especially those with diffuse axonal injury (DAI) (17.3% to 0%) ; (2) no child admitted in shock survived in the earlier period, where as 7 with GCS 4-6 survived during the recent period. Thr best model fo r mortality prediction includes GCS, and in the GCS 4-7 subgroup, the presence of subdural hematoma. It seems that the trend toward better i mmediate outcome is continuous, and this is the more striking when the severity of injury is taken into consideration. Our belief is that th e modern medical and surgical techniques, although incurring higher co sts and necessitating ongoing intensity, are well worth the effort.