RESUMEN
BACKGROUND: Expeditious care within minutes of severe injury improves outcome and is the driving force for development of trauma care systems. Transition from hospital care to rehabilitation is an important step in recovery after trauma-related injury. We hypothesize that delay in the transition from acute care to rehabilitation adversely affects outcome and diminishes recovery after traumatic brain injury (TBI). METHODS: After institutional review board approval, the trauma registry of our regional level I pediatric trauma center was queried for all children with severe blunt TBI (initial Glasgow Coma Scale score =8) that required inpatient rehabilitation. Records were stratified as severe TBI (Glasgow Coma Scale [GCS] scores 3, 4, 5) and moderate TBI (GSC scores 6, 7, 8). Intensity of acute care was defined by need for mechanical ventilation and length of intensive care unit stay. Outcome was defined by functional independence measurement (FIM) scores at time of transfer to inpatient rehabilitation. Linear regression was used to compare time in days between discharge from intensive care and admission to inpatient rehabilitation (delay) to rehabilitation efficiency (RE), defined as the ratio of FIM score improvement to length of stay for inpatient rehabilitation. Functional improvement was determined by analysis of FIM score improvement (DeltaFIM) between initiation and completion of inpatient rehabilitation. RESULTS: Between January 2000 and December 2006, 60 children (38 males, mean age, 11.2 years; 22 females, mean age, 10.6 years) with blunt TBI and an initial GCS score of 8 or lower required resuscitation, comprehensive critical care, and inpatient rehabilitation. Mean length of stay in the intensive care unit was 11.1 +/- 7.4 days. Fifty-two children required an average of 9.4 +/- 6.8 ventilator days. Delay ranged between 0 and 24 days (mean, 4.1 days) and was significantly correlated with RE and DeltaFIM (correlation coefficient = -0.346, P = .0068). For children with the highest potential for salvage (GCS scores 6, 7, 8), RE correlation increased to -0.457 (P = .011), whereas those with most severe injury (GCS scores 3, 4, 5) demonstrated a weaker correlation that was not significant. For children with most severe injury (GCS scores 3,4,5), the correlation of DeltaFIM was significant (-0.38; P = .035); however, RE was not. CONCLUSIONS: These data demonstrate the price of delay of comprehensive rehabilitation, especially for the most vulnerable TBI children with best potential for salvage. The "golden hour," which has become the mantra for continued refinement of systems of emergency and trauma care, must progress without interruption to the "golden day," during which comprehensive critical care seamlessly transitions to timely and aggressive rehabilitation to effect the greatest functional recovery.
Asunto(s)
Lesiones Encefálicas/rehabilitación , Heridas no Penetrantes/rehabilitación , Niño , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The International Classification Injury Severity Score (ICISS) uses anatomic injury diagnoses to predict probability of survival (Ps) computed as the product of the survival risk ratios (SRR) of the three most severe injuries. SRRs are derived as the proportion of fatalities for every International Classification of Diseases-9th Revision-Clinical Modification diagnosis in a "benchmark" population. Pediatric-specific SRRs were computed from 103,434 entries in the National Pediatric Trauma Registry. We hypothesized that ICISS was a valid pediatric outcome predictor, and that the child's most severe injury; i.e., the lowest SRR, is the major driver of outcome, which can be used alone to predict survival. METHODS: Receiver operator characteristic analysis was used to assess the predictive validity of ICISS. SRRs derived from 53,235 phase II patients were used as the training set to calculate the Ps for 50,199 phase III children comprising the test set. The survival probability (Ps) computed from the standard three diagnoses was compared with that computed from only the worst injury (lowest SRR). Records with a single diagnosis or Ps of 1, indicating no mortality potential, were excluded from the analysis. Nagelkerke pseudo R2 defined what proportion of the predicted Ps was the effect of the worst injury alone versus the traditional Ps. RESULTS: A total of 25,239 records with at least two diagnoses with SRRs indicating risk of mortality were analyzed. The area under the receiver operator characteristic curve for traditional Ps was 0.935, compared with 0.932 for that calculated using only the lowest SRR. The difference of 0.003 was not significant (z = 1.061, p = 0.2888, NS). Nagelkerke pseudo R2 for the lowest SRR was 0.455 compared with 0.462 for the traditional three diagnosis Ps, which shows that the majority of Ps predictive power is related to the single injury with the lowest SRR. Further analysis demonstrated that this effect was related to frequency of coexistent injuries with no mortality risk rather than definable difference in severity. CONCLUSION: These data validate ICISS as predictive of pediatric injury survival. The dominant effect of the worst injury reflects an epidemiologic characteristic of pediatric trauma that will identify specific injuries for best practice analysis and focused injury prevention.