Central-line-associated bloodstream infections in a surgical paediatric intensive care unit: Risk factors and prevention with chlorhexidine bathing.

AIM: The aims of the study are to evaluate the impact of a 4% chlorhexidine (CHG4%) bathing on the occurrence of central-line-associated bloodstream infection (CLABSI) and to identify risk factors (RFs) for CLABSI in our population. This is a retrospective monocentric cohort study in the paediatric surgical intensive care unit at the Necker Enfants Malades Hospital, Paris, France. METHODS: All hospitalised patients with central venous catheters (CVCs) in 2015 were included. CHG4% bathing was prescribed in CLABSI high-risk patients, defined by the presence of exposition factors (EFs): constitutive or acquired immunosuppression, presence of an invasive medical device (IMD) and the carriage of Staphylococcus aureus. The overall 2015 CLABSI incidence rate was compared with 2014 CLABSI incidence rate (before CHG4% bathing). RESULTS: In all, 775 patients were analysed. Some 182 had at least one EF, and 49 received CHG4%. The incidence rates of CLABSI in 2014 and 2015 were, respectively, 6.1 and 2.3/1000 days CVC (P < 0.01). The presence of at least one EF was associated with the CLABSI's occurrence: odds ratio = 15.13 (95% confidence interval: 4.26-53.71; P < 0.0001), particularly acquired immunosuppression, IMD and S. aureus colonisation. Other RFs were age <1 year and carrying duration >16 days. CONCLUSIONS: This study showed a significant reduction in incidence of CLABSI after introduction of a targeted CHG4% bathing protocol. Presence of IMD, S. aureus colonisation, immunosuppression, age <1 year and carrying duration >16 days were CLABSI RFs. Regarding the literature, the presence of IMD seems to be underestimated in CLABSI prevention.

Pediatric intracranial empyema complicating otogenic and sinogenic infection.

OBJECTIVE: To describe and compare clinical and microbiological features, surgical and medical management, and outcomes of children with otogenic and sinogenic intracranial empyema (IE) in an institution with an established multidisciplinary protocol. To use the study findings to inform and update the institutional algorithm. METHODS: Retrospective analysis was carried out on the electronic healthcare records of all children with oto-sinogenic IE admitted in a 5-year period. RESULTS: A total of 76 patients were identified and treated according to an institutional protocol. Two distinct groups were identified: intracranial empyema related to otogenic infection (OI-IE, n = 36) or sinogenic infection (SI-IE, n = 40). SI-IE was seen in older children and had a significantly higher morbidity. Sub-dural IE was seen in a minority (n = 16) and only in SI-IE and required urgent collaborative ENT-neurosurgery. Extra-dural IE occurred more frequently and was seen in both SI-IE and OI-IE. No death and overall low morbidity were observed. Particularities found in SI-IE and OI-IE groups (as thrombosis, microbiology, antibiotic treatment, duration and outcome) permitted the delineation of these groups in our updated algorithm. CONCLUSION: The presence of a collaborative multidisciplinary protocol permits the step-wise co-ordination of care for these complex patients in our institution. All patients received prompt imaging, urgent surgical intervention, and antibiotic treatment. Microbiological identification was possible for each patient and antibiotic rationalization was permitted through use of Polymerase chain reaction (PCR) testing in cases of sterile cultures. Of note, intracranial empyema related to sinogenic infection is shown to have significantly more severe clinical presentation, a higher morbidity, and a longer duration of antibiotic therapy than that related to otogenic infection. Study findings allowed for the update and clarification of the institutional protocol, which now clearly demarcates the clinical presentation, biological evidence, radiology, surgical and medical treatments in children with oto-sinogenic IE.

Current ciprofloxacin usage in children hospitalized in a referral hospital in Paris.

BACKGROUND: Fluoroquinolones are used with increasing frequency in children with a major risk of increasing the emergence of FQ resistance. FQ use has expanded off-label for primary antibacterial prophylaxis or treatment of infections in immune-compromised children and life-threatening multi-resistant bacteria infections. Here we assessed the prescriptions of ciprofloxacin in a pediatric cohort and their appropriateness. METHODS: A monocenter audit of ciprofloxacin prescription was conducted for six months in a University hospital in Paris. Infected site, bacteriological findings and indication, were evaluated in children receiving ciprofloxacin in hospital independently by 3 infectious diseases consultants and 1 hospital pharmacist. RESULTS: Ninety-eight ciprofloxacin prescriptions in children, among which 52 (53.1%) were oral and 46 (46.9%) parenteral, were collected. 45 children had an underlying condition, cystic fibrosis (CF) (21) or an innate or acquired immune deficiency (24). Among CF patients, the most frequent indication was a broncho-pulmonary Pseudomonas aeruginosa infection (20). In non-CF patient, the major indications were broncho-pulmonary (25), urinary (8), intra-abdominal (7), operative site infection (5) and bloodstream/catheter (2/4) infection. 62.2% were microbiologically documented. Twenty-three (23.4%) were considered "mandatory", 48 (49.0%) "alternative" and 27 (27.6%) "unjustified". CONCLUSION: In our university hospital, only 23.4% of fluoroquinolones prescriptions were mandatory in children, especially in Pseudomonas aeruginosa healthcare associated infection. Looking to the ecological risk of fluoroquinolones and the increase consumption in children population we think that a control program should be developed to control FQ use in children. It could be done with the help of an antimicrobial stewardship team.

Kidneys recovered from brain dead cardiac arrest patients resuscitated with ECPR show similar one-year graft survival compared to other donors.

INTRODUCTION: Among patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) as a second line of treatment for refractory out-of-hospital cardiac arrest (OHCA), some may develop brain death and become eligible for organ donation. The objective of this study was to evaluate long-term outcomes of kidney grafts recovered from these patients. MATERIAL AND METHODS: We conducted a retrospective monocentric observational study between January 1, 2011, and December 31, 2017. We exclusively included patients eligible for planned donation after brainstem death and from whom at least one organ graft was retrieved and transplanted. We compared two groups of brain dead patients: those treated with ECPR for refractory OHCA (ECPR group) and a diverse group of patients who did not receive ECPR, from which only 5/23 (22%) had OHCA (control group). The primary outcome was one-year kidney graft survival. RESULTS: We included 45 patients, 23 in the control group and 22 in the ECPR group. Although patients in the ECPR group were younger and had a lower prevalence of chronic renal disease (p = 0.01), their kidney function was more severely impaired upon admission in the ICU. A total of 68 kidney grafts were retrieved, transplanted, and studied, 34 in each study group. There was no significant difference between the two groups in terms of one-year kidney graft survival (p = 0.52). CONCLUSION: Organ transplantation from patients treated with ECPR after refractory OHCA showed one-year kidney graft survival rates comparable to those of patients not treated with ECPR.

Scaphocephaly correction with retrocoronal and prelambdoid craniotomies (Renier's "H" technique).

OBJECTIVE: The aim of this paper is to describe the surgical technique, originally devised by Dr. Renier which is currently used to treat children with scaphocephaly under 6 months of age at the Craniofacial Unit of Hopital Necker Enfants Malades (French National Referral Center for Faciocraniosynostosis), focusing on its advantages and limitations.

Listeria monocytogenes: a rare complication of ventriculoperitoneal shunt in children.

We report a case of ventriculoperitoneal (VP) shunt infection in a 3-year-old boy caused by the food-borne pathogen Listeria monocytogenes, subsequent to acute peritonitis. This unusual presentation of central nervous system (CNS) listeriosis underlines the ability of the bacteria to form and survive within biofilms on indwelling medical devices. Bacterial persistence may lead to treatment failure and spreading. We highlight the helpfulness of specific quantitative real-time PCR for the hly gene (PCR-hly) for the diagnosis and follow-up of such infections in detecting bacterial persistence within medical devices despite effective antibiotic treatment. Only the surgical replacement of the VP shunt will resolve the infection.

Emergency tracheal intubation of severely head-injured children: changing daily practice after implementation of national guidelines.

OBJECTIVE: To report daily practice of scene emergency tracheal intubation performed by physicians and changes induced by implementation of national guidelines, with special attention to rapid sequence induction (RSI) and control of assisted ventilation. DESIGN: Observational study. SETTING: Pediatric intensive care unit of a university hospital. PATIENTS: A total of 296 children (age, 2-15 yrs old) referred to our center for severe traumatic brain injury (Glasgow Coma Scale score of ≤ 8), with spontaneous cardiac rhythm. INTERVENTIONS: Scene RSI practice by field physicians was compared before (n = 188), and after (n = 108) publication of national guidelines. Emergency tracheal intubation conditions, RSI use, immediate complications, assisted ventilation efficiency on blood gases measurements upon arrival, and, in the later period, physician's knowledge, and observance to published guidelines were analyzed. MEASUREMENTS AND MAIN RESULTS: After publication of guidelines, tracheal intubation was performed at the scene in 100% of the cases (vs. 88%, p = .05); RSI practice was more standardized, with an increased use of succinylcholine (10% to 80%, p = .0001), and a concomitant decreased use of nondepolarizing muscle relaxant (20% vs. 0%, p = .005), and opioids (70% vs. 36%, p = .05). Recommended RSI protocol (etomidate and succinylcholine) was effectively used by 64% of the physicians (vs. 2.8%, p = .001), and rate of immediate complications upon tube insertion (mainly cough reflex) decreased to 8% (vs. 25%, p = .0015). Scene emergency tracheal intubation, when ordered, resulted in a 100% success rate and adequate oxygenation within the two groups. Despite increasing the use of portable capnograph in the later period, Paco2 was measured outside the tight target range (35-40 torr, 4.6-5.3 kPa) in 70% of the cases upon arrival. CONCLUSIONS: Scene emergency tracheal intubation was effectively performed by trained careproviders in children with traumatic brain injury. Implementation of guidelines led to a more standardized practice of RSI, decreased rate of immediate complications, but insufficient control of Paco2 during transport.

Transcranial Doppler can predict intracranial hypertension in children with severe traumatic brain injuries.

PURPOSE: The purpose of this study is to evaluate the accuracy of emergency Transcranial Doppler (TCD) to predict intracranial hypertension and abnormal cerebral perfusion pressure in children with severe traumatic brain injury (TBI). PATIENTS AND METHODS: A descriptive and retrospective cross-sectional study was designed through data collected from medical records of children with severe TBI (Glasgow coma scale ≤ 8), admitted to a level I pediatric trauma center, between January 2000 and December 2005. Early TCD examination was performed upon admission, and TCD profiles were considered as altered using previously validated threshold values for diastolic velocity (<25 cm/s) and pulsatility index (>1.31) or when no-flow/backflow was detected. Invasive intracranial pressure (ICP) and cerebral perfusion pressure (CPP) monitoring were considered as the gold standard to measure intracranial hypertension (ICH). Statistical analyses compared TCD profiles to increased ICP (≥ 20 mmHg) and abnormal cerebral perfusion pressure (<50 mmHg) at admission. RESULTS: Non-invasive TCD and ICP monitoring were performed in 117 severe head-injured children. Mean age was 7.6 ± 4.4 years, with a male prevalence (71%). Median initial Glasgow coma scale was 6. TCD had 94% of sensitivity to identify ICH at admission and a negative predict value of 95% to identify normal ICP at admission. Its sensitivity to predict abnormal cerebral perfusion pressure was 80%. CONCLUSIONS: The high sensitivity of admission TCD to predict ICH and abnormal CPP after trauma demonstrates that TCD is an excellent first-line examination to determine those children who need urgent aggressive treatment and continuous invasive ICP monitoring.

Acute hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury.

PURPOSE: Hyperglycemia in the acute phase after trauma could adversely affect outcome in children with severe traumatic brain injury (TBI). The goal of this study was to identify the relationship between acute spontaneous hyperglycemia and outcome in children with severe TBI at hospital discharge and 6 months later. METHODS: A retrospective analysis of blood glucose levels in children with severe TBI at a Pediatric level I Trauma Center, between January 2000 and December 2005. Hyperglycemia was considered for a cut-off value of 11.1 mmol/l (200 mg/dl). Outcome was measured with Glasgow Outcome Scale (GOS) at hospital discharge and at 6 months. A multiple logistic regression analysis, the Student's t test and the chi (2) test were done. RESULTS: Hyperglycemia was noted within the first 48 h in 34% of the patients. Mortality (70% vs 14%, p < 10(-5)) was more frequent in hyperglycemic children and bad outcome upon hospital discharge in those who remained hyperglycemic during the first 48 h of hospitalization. GOS after 6 months demonstrated that those normoglycemic children had a better outcome (95%) than those who developed hyperglycemia during the first 48 h (83%, p = 0.01) after trauma. CONCLUSION: Hyperglycemia could be considered as a marker of brain injury and when present upon admission, could reflect extensive brain damage with frequently associated mortality and bad outcome. The inability to maintain normal blood glucose levels during the first 48 h could be a predictive factor of bad outcome. Avoiding hyperglycemia in the initial phase could be a major issue in children with severe TBI.

Brain abscess in children, a two-centre audit: outcomes and controversies.

OBJECTIVE: The aim of this study was to better characterise clinical presentation, management and outcome in infants and children with brain abscess. METHODS: The authors conducted a retrospective, multicentre study in two national reference centres over a 25-year period (1992-2017). During this period, 116 children and 28 infants (age <1 year) with brain abscess were treated. RESULTS: The median age at diagnosis was 101.5 (range: 13-213) months in children and 1 (0-11) month in infants. Significant differences were observed between children and infants. The most common predisposing factor was meningitis in infants (64% of cases vs 3% in children), while it was otolaryngology-related infection in children (31% of cases vs 3.6% in infants). Infants presented more frequently with fever and meningism compared with children. 115 patients were treated with aspiration and 11 with excision. Reoperation was required in 29 children vs 1 infant. The overall mortality rate was 4% (3.4% for children, 7.1% for infants). At 3-month follow-up, the outcome was favourable in 86% of children vs in 68% of infants. CONCLUSION: There is a clear difference between children and infants with brain abscess in terms of predisposing factors, causative organisms and outcome. Despite surgical drainage and directed antibiotic therapy, 25% of patients with brain abscess require reoperation. Mortality is improved compared with historical series; however, long-term morbidity is significant particularly in the infant population.

Paediatric intracranial empyema: differences according to age.

No recent studies are available which consider the epidemiology and outcome of paediatric intracranial empyema (PICE). We retrospectively studied all PICE cases admitted in our institution from 1993 to 2006. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 24 months. Aetiology, clinical features, therapeutic considerations and risk factors of poor outcome were analysed according to age. Data from 38 patients were studied; 33/38 presented with subdural empyema (SDE) and 5/38 with extradural empyema (EDE); 10/38 were infants <1 year of age with SDE, all related to bacterial meningitis; 28/38 were children, with 23/28 showing SDE and 5/28 EDE. Oto-sinogenic infections were the main causes in children. All infants recovered completely as did children with EDE. However, two out of 23 children with SDE had permanent neurological deficit, already detected on admission, and one out of 23 died. Thirty-three out of 38 were operated; 16 of which underwent multiple surgical procedure because of recurrence. Burr hole was performed in six infants and craniotomy in one, while 21/23 children underwent burr hole or craniotomy. Burr hole was more often associated with recurrence. In children with SDE, factors associated with poor outcome were neurological deficit (p = 0.002) and cerebral herniation on CT scan (p = 0.02) on admission. In this study, we gained further insights into modern epidemiology of PICE by highlighting age-related aetiology, symptoms, treatment strategy, and outcome differences. Meningitis was the main aetiology in the infants and sinusitis was prevalent in children. Finally, early diagnosis by neuro-imaging investigations and timely and appropriate multidisciplinary treatment may offer the best chance of recovery.

Admission base deficit as a long-term prognostic factor in severe pediatric trauma patients.

BACKGROUND: Base deficit (BD) is a prognostic tool that correlates with trauma scores and mortality in adult trauma patients. Retrospective studies have shown that admission BD more than 8 mmol/L is associated with an increased risk of mortality. This is the first prospective European study aimed at evaluating the prognostic value of admission BD in traumatized children. METHODS: One hundred severely traumatized children were included if an arterial BD had been calculated on arrival in the trauma room of a university hospital. Epidemiologic, medical, and biological data (including admission BD and lactates concentration) were recorded and compared using a univariate analysis. The primary endpoint was in-hospital mortality. Secondary endpoints were outcome on discharge and at 6 months. Cutoff values for BD or lactates regarding outcomes were determined using receiver operating characteristic curves if these data had been isolated on multivariate analysis (p < 0.05). RESULTS: Sixty-eight boys and 32 girls, aged 6.7 years, were enrolled from March 2003 to December 2005, mainly after road traffic accidents. Twenty-two died at the hospital, 34 children and 51 children were classified as having a good outcome on hospital discharge and 6 months later, respectively. After the multivariate procedure and receiver operating characteristic curve analysis, admission lactates more than 2.94 mmol/L and admission BD more than 5 mEq/L were independent risk factors for mortality (odds ratio 2.4 [95% confidence interval 1.3-4.6]) and poor outcome at 6 months (odds ratio 2.5 [95% confidence interval 1.13-5.5]), respectively. DISCUSSION: BD could be used to predict the long-term morbidity and may not be related to morbidity and mortality at discharge.

Misuse of an adult seat belt in a 7-year-old child: a source of dramatic injuries and a plea for booster seat use.

Children involved in high-speed vehicle collision could be particularly exposed to severe injuries when adult restraints are used. We report a case where adult 3-point restraint used without booster seat was responsible for severe thoracic injury resulting in complete shoulder and clavicle dislocation, occipito-atloidal dislocation, and complete disruption of right common carotid artery in a 7-year-old boy. Misplacement of the adult shoulder harness at the base of the neck could be directly responsible for these lethal injuries, which could probably be avoided by concomitant use of a booster seat.

Fulminant Nocardiosis Due to a Multidrug-Resistant Isolate in a 12-Year-Old Immunocompetent Child.

Nocardiosis is a rare cause of infection that usually affects immunocompromised adult patients and might not be recognized by pediatricians. We report a fatal case of disseminated nocardiosis in a previously healthy child initially admitted for an abdominal mass with suspicion of a renal malignant tumor. The patient, originating from Mali without any medical history, displayed abdominal pain with progressive altered general status. Laboratory and imaging findings revealed lymphocytic meningitis and disseminated abscesses in the brain and the cerebellum and a large number of cystic lesions of the kidney. Despite being administered wide-spectrum antibiotics and antituberculous and antifungal therapies with an external ventricular drainage for intracranial hypertension, the patient died 6 days after his admission. Nocardia spp was cultured from a renal biopsy and the cerebrospinal fluid. Species identification and antibiotic susceptibility were obtained later, revealing a multidrug-resistant isolate of the Nocardia elegans/aobensis/africana complex. This case reveals the difficulties of diagnosing nocardiosis, in particular in children not known to be immunocompromised, because we face multiple differential diagnoses and the importance of treating nocardiosis appropriately because of intrinsic resistance issues.

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures.

OBJECTIVE:: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN:: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING:: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS:: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS:: Intravenous administration of recombinant activated factor VII (100 mug/kg). RESULTS:: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS:: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Use of recombinant activated factor VII in intractable bleeding during pediatric neurosurgical procedures.

OBJECTIVE: To report the use of recombinant activated factor VII (NovoSeven; Novo Nordisk A/S, Bagsvaerd, Denmark) in children undergoing major neurosurgical procedures and experiencing massive uncontrolled hemorrhagic shock. DESIGN: Retrospective review of patients and analysis of clinical and biological effects of an intravenous administration of recombinant activated factor VII. SETTING: Neurosurgical anesthesia and critical care unit of a pediatric university hospital. PATIENTS/SUBJECTS: Four children, <12-kg body weight, experiencing life-threatening perioperative hemorrhage required conventional treatment (massive red blood cells, fresh frozen plasma, platelet transfusion, and surgical hemostatic maneuvers) that failed to obtain definite hemostasis. INTERVENTIONS: Intravenous administration of recombinant activated factor VII (100 microg/kg). RESULTS: Intravenous administration resulted in a significant decrease in blood loss within minutes (preventing further need of transfusion), normalization of biological hemostasis markers, and improved surgical hemostasis. No side effects of recombinant activated factor VII were noted, and all patients, except one, had a good recovery. CONCLUSIONS: These four patients support the use of recombinant activated factor VII as a useful adjunct to control massive life-threatening bleeding during pediatric neurosurgical procedures when other means failed. However, the data are still limited in children, and more extensive research is needed to define the indications of recombinant activated factor VII in massive surgical hemorrhage in low-weight children.

Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center.

OBJECTIVE: To describe the results of an integrated pre- and in-hospital approach to critical care in a large population of children with severe traumatic brain injury and to identify the early predictors of their outcome. DESIGN: A 9-yr retrospective review of the data of a trauma data bank. SETTING: Level III pediatric trauma center. PATIENTS: All children (1 month to 15 yrs) with severe traumatic brain injury (Glasgow Coma Scale /=6 months after discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Univariate and further multivariate analyses were performed to determine independent predictive factors of death and outcome at discharge and 6 months later. The Glasgow Outcome Scale was used to evaluate outcome; a poor outcome referred to Glasgow Outcome Scale >/=3. Receiver operating characteristic curves were drawn to determine the threshold values of predictors of death and outcome. Analysis concerned 585 children (67% male and 33% female). Mean age was 7 +/- 5 yrs. Predominant mechanisms of injury were road traffic accidents and falls. Mean values for Glasgow Coma Scale, Pediatric Trauma Score, and Injury Severity Score were 6 (3-8), 3 (-4,10), and 28 (4-75), respectively. Mortality rate was 22%; Glasgow Outcome Scale was <3 in 53% of the cases at discharge and 60% at 6 months. Multivariate analysis identified Glasgow Coma Scale, Injury Severity Score, and hypotension on arrival as independent predictors of death and poor outcome at discharge and at 6 months. Threshold values for death were 28 for Injury Severity Score and 5 for Glasgow Coma Scale. The same values were found for poor outcome, except for outcome at 6 months where threshold value for the Glasgow Coma Scale was 6. CONCLUSIONS: Initial hypotension, Glasgow Coma Scale, and Injury Severity Score are independent predictors of outcome in children with traumatic brain injury. Threshold values can be calculated for predicting poor outcome. These variables can be easily and detected early in this population and used for quality assessment.

The prognostic value of transcranial Doppler studies in children with moderate and severe head injury.

OBJECTIVE: To assess the potency of transcranial Doppler (TCD) to predict prognosis in children with moderate and severe head trauma. DESIGN AND SETTING: Prospective single-center study in a level I pediatric trauma center. PATIENTS: Thirty-six consecutive patients with a prehospital diagnosis of moderate or severe head trauma admitted over a 6-month period. INTERVENTIONS: On arrival in the emergency room, TCD was performed and peak systolic velocities, end-diastolic velocity and time-averaged mean velocity in the middle cerebral artery were recorded. Pulsatility and resistance index were calculated. The Pediatric Trauma Score (PTS), Glasgow Coma Scale (GCS) score and Injury Severity Score (ISS) were also calculated. Patient neurological outcome was determined using the Glasgow Outcome Scale (GOS) at discharge from hospital. GOS 1-2 were considered as "good prognosis" (group 1) and GOS 3-5 were considered as "poor prognosis" (group 2). RESULTS. Compared with group 1 patients, group 2 patients had a significantly lower mean GCS (5+/-3 vs 8+/-4, p<0.05) and PTS (2+/-2 vs 5+/-2), and a higher mean ISS (32+/-8 vs 19+/-11, p<0.05). An end-diastolic velocity less than 25 cm/s and a pulsatility index more than 1.31 were associated with a poor prognosis (p<0.05). CONCLUSION: In children with moderate and severe head trauma, our data suggest an association between the results of TCD assessment on arrival in the emergency room and the outcome at discharge from the hospital.