SURVIVAL AND FUNCTIONAL OUTCOME OF CHILDREN REQUIRING ENDOTRACHEAL INTUBATION DURING THERAPY FOR SEVERE TRAUMATIC BRAIN INJURY

Objective: To determine the predictors of survival and functional outc ome of pediatric patients with traumatic brain injury severe enough to require endotracheal intubation and mechanical ventilation. Design: R etrospective, observational cohort study. Setting: Pediatric intensive care unit (ICU) at a tertiary care children's hospital. Patients: All children (n =105) admitted over a 5-yr period with traumatic brain in jury severe enough to require endotracheal intubation and mechanical v entilation, The median age was 43 months (range 1 month to 14 yrs), Of these children, 74% were male and 70% were white. Interventions: None . Measurements and Main Results: Variables studied included vital sign s during the first 24 hrs of admission, Pediatric Risk of Mortality (P RISM) score, Glasgow Coma Score, duration of mechanical ventilation, a nd number of pediatric ICU and hospital days, Functional status was gr aded as normal, independent, partially dependent, or dependent in the areas of locomotion, self-care, and communication, This status was ass essed at hospital discharge by chart review and at follow-up by teleph one interview, The median Glasgow Coma Score was 6 (range 3 to 14) and the median PRISM score was 13 (range 1 to 51). There were 19 (18.1%) deaths, 17 in the pediatric ICU and two after hospital discharge, Of t he patients who survived to hospital discharge, 39 (37.1%) patients we re completely normal or independent, 42 (40%) patients were partially dependent, and seven (6.7%) patients were dependent in all three areas of function, Follow-up evaluations were available for 80 patients, wi th a median follow-up time of 24.5 months (range 8 to 70), Of the 78 p atients who survived and were available for follow-up, the number who were functionally normal or independent increased to 69 (65.7%), At fo llow-up, there were eight (7.6%) patients remaining with partial depen dency in at least one area of function while one (0.9%) patient contin ued to be dependent in all three areas of function, Mortality and depe ndent functional outcome were more likely in patients with younger age , lower Glasgow Coma Score, and higher PRISM score at hospital admissi on, Of the 27 patients with a Glasgow Coma Score of less than or equal to 5, 11 (40.7%) survived with normal or independent functional statu s at follow up. Of the 24 patients with PRISM scores of greater than o r equal to 20, only five (20.8%) were functionally normal or independe nt at follow-up, The relative risk of a bad outcome for patients with a Glasgow Coma Score of less than or equal to 5 and a PRISM score of g reater than or equal to 20 was ten times higher than the group of pati ents with a Glasgow Coma Score of less than or equal to 5 but a PRISM score of <20. Conclusions: Children with severe traumatic brain injury who survive to hospital discharge will continue to improve in their f unctional status over the next few years, Although low Glasgow Coma Sc ore is strongly associated with death or poor functional outcome after therapy for traumatic brain injury, many patients with Glasgow Coma S core of less than or equal to 5 can Survive with good function. PRISM scores add to the power of Glasgow Coma Score to predict survival and functional outcome in tracheally intubated pediatric patients with Gla sgow Coma Score of less than or equal to 5.