Indications for prehospital intubation among severely injured children and the prevalence of significant traumatic brain injury among those intubated due to impaired level of consciousness.

BACKGROUND: Prehospital endotracheal intubation (PEI) of head injured children with impaired level of consciousness (LOC) aims to minimize secondary brain injury. However, PEI is controversial in otherwise stable children. We aimed to investigate the indications for PEI among pediatric trauma patients and the prevalence of clinically significant traumatic brain injury (csTBI) among those intubated solely due to impaired consciousness. METHODS: This is a multicenter retrospective cohort study of children who underwent PEI in northern Israel between January 2014 and December 2020 by six EMS agencies and were transported to two trauma centers in the area. We extracted data from EMS records and trauma registries. RESULTS: PEI was attempted in 179/986 (18.2%) patients and was successful in 92.2% of cases. Common indications for PEI were hypoxemia not corrected by supplemental oxygen (n = 30), traumatic cardiac arrest (n = 16), and facial injury compromising the airway (n = 13). 112 patients (62.6%) were intubated solely due to impaired or deteriorating LOC. Among these patients, 68 (62.4%) suffered csTBI. The prevalence of csTBI among those with field Glasgow Coma Scale (GCS) of 3, 4-8, and > 8 was 81.4%, 55.8%, and 28.6%, respectively (p < 0.001). Among children ≤ 10 years old intubated due to impaired LOC, 50% had csTBI. CONCLUSION: Impaired LOC is a major indication for PEI. However, a significant proportion of these patients do not suffer csTBI. Older age and lower pre-intubation GCS are associated with more accurate field classification. Our data indicate that further investigation and better characterization of patients who may benefit from PEI is necessary.

Admission hypocalcemia in pediatric major trauma patients-An uncommon phenomenon associated with an increased need for urgent blood transfusion.

BACKGROUND: Hemorrhage is a leading cause of death among children. Recent data from adult trauma suggests that early, transfusion-unrelated, hypocalcemia is common and that it is associated with an increased need for blood transfusion, mortality, and coagulopathy. The objectives of this study are to evaluate the prevalence of admission hypocalcemia in severely injured children and its correlation with urgent blood transfusion. STUDY DESIGN AND METHODS: This is a retrospective cohort study of all severely injured (Injury Severity Score [ISS] > 15) pediatric (<18 years) trauma patients admitted to Rambam Health Care Campus, Israel between 2012 and 2020. We excluded patients transferred from other facilities and those who received blood before determining calcium levels. Severe hypocalcemia was defined as ionized calcium (Ca++ ) < 1.0 mmol/L and mild hypocalcemia as 1.0 mmol/L ≤ Ca++  < 1.1 mmol/L. The primary outcome was urgent blood transfusion (transfusion in the emergency department [ED]). RESULTS: Six hundred seventy-three severely injured children were admitted from the field. Ca++ levels were determined before blood transfusion in 457 patients. Severe hypocalcemia was found in three patients (0.7%) and mild hypocalcemia in additional 21 patients (4.6%). Hypocalcemic patients required more urgent blood transfusion (29.2% vs. 6.5%, p < .001) and had higher ISS (29 [interquartile range, IQR: 22-35] vs. 25 [IQR: 19-34], p = .05). Multivariable logistic regression analysis identified Ca++  < 1.1 mmol/L as an independent predictor of the need for blood transfusion, odds ratio 5.44 (95% confidence interval 1.44-20.58), p = .01. DISCUSSION: Contrary to adults, admission hypocalcemia is uncommon in severely injured children. However, it may be associated with an increased risk of blood transfusion in the ED.

Prevalence of significant traumatic brain injury among patients intubated in the field due to impaired level of consciousness.

OBJECTIVE: Current guidelines advocate prehospital endotracheal intubation (ETI) in patients with suspected severe head injury and impaired level of consciousness. However, the ability to identify patients with traumatic brain injury (TBI) in the prehospital setting is limited and prehospital ETI carries a high complication rate. We investigated the prevalence of significant TBI among patients intubated in the field for that reason. METHODS: Data were retrospectively collected from emergency medical services and hospital records of trauma patients for whom prehospital ETI was attempted and who were transferred to Rambam Health Care Campus, Israel. The indication for ETI was extracted. The primary outcome was significant TBI (clinical or radiographic) among patients intubated due to suspected severe head trauma. RESULTS: In 57.3% (379/662) of the trauma patients, ETI was attempted due to impaired consciousness. 349 patients were included in the final analysis: 82.8% were male, the median age was 34 years (IQR 23.0-57.3), and 95.7% suffered blunt trauma. 253 patients (72.5%) had significant TBI. In a multivariable analysis, Glasgow Coma Scale>8 and alcohol intoxication were associated with a lower risk of TBI with OR of 0.26 (95% CI 0.13-0.51, p < 0.001) and 0.16 (95% CI 0.06-0.46, p < 0.001), respectively. CONCLUSION: Altered mental status in the setting of trauma is a major reason for prehospital ETI. Although most of these patients had TBI, one in four of them did not suffer a significant TBI. Patients with a higher field GCS and those suffering from intoxication have a higher risk of misdiagnosis. Future studies should explore better tools for prehospital assessment of TBI and ways to better define and characterize patients who may benefit from early ETI.

Head- and neck-related symptoms post-motor vehicle collision (MVC): Separate entities or two-sides of the same coin?

BACKGROUND AND AIM: Although post-motor vehicle collision (MVC) pain and symptoms are largely convergent among those with mild traumatic brain injury (mTBI) and whiplash associated disorder (WAD), and patients oftentimes report initial neck and head complaints, the clinical picture of mTBI and WAD has been primarily studied as separate conditions which may result in an incomplete clinical picture. As such, this study was conducted to explore the role of pain and post-traumatic psychological features in explaining both head and neck-related symptom variability in a cohort of post-collision patients. This is with the goal of disentangling if contributory factors are uniquely related to each diagnosis, or are shared between the two. METHODS: Patients recruited in the very early acute phase (<72 h) returned for clinical and psychological assessment at 6 months post-accident. In order to determine which factors were unique and which ones were overlapping the same potential contributors: mean head pain, mean neck pain, female gender, number of post-collision painful body areas, PTSD, and depression were included in the regression models for both neck disability index (NDI) and Rivermead post-concussion symptoms questionnaire (RPQ). RESULTS: Of 223 recruited participants, 70 returned for a follow-up visit (age range 18-64, mean(SD) 37.6 (11.9), 29F). This cohort primarily met the criteria for mTBI, but also fulfilled the criteria for whiplash, reinforcing the duality of injury presentation. Correlations existed between the NDI and RPQ scores (Spearman's ρ=0.66, p<0.001), however overlap was only partial. Regression analysis showed that after the removal of area-of-injury pain neck related disability (r = 0.80, p <0.001) was explained solely by number of painful body areas (ß=0.52, p <0.001). In contrast, post-concussion syndrome symptoms (r = 0.86, p<0.001) are influenced by clinical pain, painful body areas (ß=0.31, p = 0.0026), female gender (ß=0.19, p = 0.0053), and psychological factors of depression (ß=0.31, p = 0.0028) and PTSD symptoms (ß=0.36, p = 0.0013). CONCLUSIONS: It seems that while mechanisms of neck- and head-related symptoms in post-collision patients do share a common explanatory feature, of residual body pain, they are not entirely overlapping. In that psychological factors influence post-concussion syndrome symptoms, but not post-whiplash neck disability.

Explaining very early acute mild traumatic brain injury after motor vehicle collision pain variability: additive value of pain sensitivity questionnaire.

INTRODUCTION AND OBJECTIVES: Chronic pain is a common postcollision consequence. Wherein, a clearer understanding of acute pain can help stem the acute-to-chronic pain transition. However, the variability of acute pain is only partially explained by psychophysical pain characteristics as measured by quantitative sensory testing. The Pain Sensitivity Questionnaire (PSQ) may reflect inherent psychocognitive representations of patient's sensitivity and thus may reveal less-explored pain dimensions. In the vein of the biopsychosocial approach, this study aimed to explore whether PSQ holds additive value in explaining head and neck pain reports in very early acute-stage mild traumatic brain injury (mTBI) after collision, above the use of psychophysical assessment. METHODS: Study cohort (n = 130) consisted of mTBI patients (age range 19-66, 57 F) after accident with area-of-injury pain of at least 20 on the day of testing (mean pain 58.4 ± 21.6, range 20-100 Numerical Pain Scale) who underwent clinical, psychophysical, and pain-related psychological assessment within 72-hour after injury. RESULTS: Pain Sensitivity Questionnaire scores were significantly correlated with acute clinical, psychophysical, and pain-related psychological measures. Regression model (R 2 = 0.241, P < 0.001) showed that, together, age, sex, high PSQ, enhanced temporal summation, and less-efficient conditioned pain modulation explained head and neck pain variance. This model demonstrated that the strongest contribution to degree of postinjury pain was independently explained by PSQ (ß = 0.32) and then pressure pain threshold-conditioned pain modulation (ß = -0.25). CONCLUSION: Appraisal of cognitive daily-pain representations, by way of memory and imagination, provides an additional important dispositional facet to explain the variability in the acute mTBI postcollision clinical pain experience, above assessing nociceptive responsiveness to experimentally induced pain.

Procedural sedation in non-intubated children with severe trauma - A single center study.

BACKGROUND: Non-intubated children frequently undergo emergent procedures in the trauma-bay. This study evaluates whether patients treated with procedural sedation have an increased risk for severe adverse events. METHODS: Retrospective analysis of 1182 children with an injury severity score (ISS) of greater than 15. RESULTS: Of the 565 patients who were spontaneously breathing on arrival, 455 were hemodynamically stable with a Glasgow Coma Score of 15, 201 of whom were treated with sedation; 144 (71.6%) had computerized tomography scan, 35 (17.5%) wound debridement, and 22 (10.9%) fracture reduction. Sedation patients had an ISS of 20 (interquartile range 17-25). There were no death cases, no cases of cardiopulmonary resuscitation, and no cases of neurologic sequelae on hospital discharge. There were 2 (1%) cases of unanticipated endotracheal intubation. CONCLUSIONS: Non-intubated patients who were hemodynamically stable with a Glasgow Coma Score of 15 had a low risk for severe adverse events due to sedation.

Psychophysic-psychological dichotomy in very early acute mTBI pain: A prospective study.

OBJECTIVE: To characterize the pain-related somatosensory and psychological presentation of very early acute patients with a mild traumatic brain injury (mTBI). METHODS: Patients with an mTBI participated in a prospective observational study undergoing clinical, psychophysic, and psychological assessment within 72 hours after the accident. Healthy controls underwent similar protocol. RESULTS: One hundred acute patients with an mTBI (age 36 ± 12.5 [SD] years, range 19-67 years, 42 women) and 80 healthy controls (age 43 ± 14.3 years, range 24-74 years, 40 women) participated. Patients with an mTBI demonstrated a pronociceptive psychophysic response in most tests such as less efficient pressure-pain threshold-conditioned pain modulation (0.19 ±0.19±.09 vs. 0.91±.10 kg, p < 0.001) and lower temperature needed to elicit a Pain50 response (44.72 ± 0.26°C vs 46.41 ± 0.30°C, p < 0.001). Their psychophysic findings correlated with clinical pain measures, e.g., Pain50 temperature and mean head (r = -0.21, p = 0.045) and neck (r = -0.26, p = 0.011) pain. The pain-catastrophizing magnification subscale was the only psychological variable to show a difference from the controls, while no significant correlations were found between any psychological measures and the clinical or psychophysic pain measures. CONCLUSIONS: There appears to be a dichotomy between somatosensory and psychological findings in the very early acute post-mTBI stage; while the first is altered and is associated with the clinical picture, the second is unchanged. In the context of the ongoing debate on the pathophysiologic nature of the post-mTBI syndrome, our findings support its "physical" basis, free of mental influence, at least in the short time window after the injury.