gms | German Medical Science

Background: Severe Traumatic Brain Injury (TBI) remains a life-threatening disorder down to the present day. Prognostic factors to develop treatment strategies and allocating treatment sources are essential. These decisions are often based on the initial Glasgow Coma Scale (GCS), pupil size as well as the pupil reaction. Finally the age of the patient is a general accepted prognostic parameter. Nevertheless not much data on the impact of these factors in severe TBI exists. Aim of this retrospective multicentre study was to evaluate the prognostic impact of the GCS, pupillary status and patient’s age on mortality and outcome in severe TBI.

Materials and methods: The TraumaRegister DGU^® was retrospectively analysed from 2002-2013 for patients, aged 0-55 years, suffering from a leading TBI with an Abbreviated Injury Scale (AIS) in head of ≥3 and an AIS in any other part of the body not exceeding the AIS of the head. The cohort was divided into a paediatric group (0-15 years of age) and an adult group (16-55 years of age). Data were obtained with a special focus on the GCS component motor response, pupil size and pupil reaction and categorized according to the recently implemented Eppendorf-Cologne-Scale (ECS). Outcome at discharge was measured by the Glasgow Outcome Scale (GOS). Adjusted univariate analysis was performed followed by stepwise multivariate logistic regression analysis.

Results: 9906 patients fulfilled the study inclusion criteria and complete data sets were available. 883 patients were ≤15 years (8.9%) with a median of 10 years. A GCS of ≤8 was documented in 47.4% of all patients ≤15 years vs. 50.3% in the adult group. The overall mortality rate was higher in adults compared to the paediatric group (19.9% vs. 16.3). Patients presenting with a GCS of 3 and bilateral fixed and dilated pupils, representing an ECD of 8, had a mortality rate of 85% for adults while paediatric patients died in 80.9%. The overall outcome in the paediatric group was higher with a favourable GOS 4-5 in 72.2% in all cases in contrast to a favourable outcome of 63.1% for the adults, although cardiopulmonary resuscitation rates were higher in paediatric patients (8.9% vs. 5.7%). In the multivariate logistic regression analysis no motor response (Odds ratio (OR) 4.359 95% confidence interval (CI) [2.922-6.503]), fixed (OR 4.556 [95%CI 3.654-5.681]) and bilateral dilated pupils (OR 3.185 [95%CI 2.628-3.860]) were associated with a higher mortality. Patients ≤15 years of age had a statistical lower rate of mortality with an OR of 0.672 [95%CI 0.510-0.884].

Conclusion: Paediatric patients, ≤15 years of age, with severe TBI have a lower mortality rate and better outcome in contrast to adults, although cardiopulmonary resuscitation rates were higher. Missing motor response as well as fixed and/or bilateral dilated pupils are associated with a higher mortality rate of up to 85% for adults and 80.9% for paediatric patients. Nevertheless these mortality rates are still lower than known from publications up to date and might encourage treating these patients in an aggressive manner.