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Cushing's Sign and Severe Traumatic Brain Injury in Children

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Cushing's Sign and Severe Traumatic Brain Injury in Children Open Access Research BMJ Open: first published as 10.1136/bmjopen-2017-020781 on 3 March 2018. Downloaded from Cushing’s sign and severe traumatic brain injury in children after blunt trauma: a nationwide retrospective cohort study in Japan Tetsuya Yumoto,1,2 Hiromichi Naito,1 Takashi Yorifuji,3 Hiroki Maeyama,2 Yoshinori Kosaki,1 Hirotsugu Yamamoto,1 Kohei Tsukahara,1 Takaaki Osako,1 Atsunori Nakao1,2 To cite: Yumoto T, Naito H, ABSTRACT Strength and limitations of this study Yorifuji T, et al. Cushing’s Objective We tested whether Cushing’s sign could predict sign and severe traumatic severe traumatic brain injury (TBI) requiring immediate ► A nationwide retrospective cohort study from Japan brain injury in children after neurosurgical intervention (BI-NSI) in children after blunt blunt trauma: a nationwide Trauma Data Bank. trauma. retrospective cohort study ► Relationship between Cushing’s sign and severe Retrospective cohort study using Japan Trauma in Japan. BMJ Open Design traumatic brain injury requiring immediate 2018;8:e020781. doi:10.1136/ Data Bank. neurosurgical intervention in paediatric patients bmjopen-2017-020781 Setting Emergency and critical care centres in secondary with traumatic brain injury using a multiple logistic and tertiary hospitals in Japan. Prepublication history and regression model. ► Participants Children between the ages of 2 and 15 additional material for this ► A large number of patients were excluded due to paper are available online. To years with Glasgow Coma Scale motor scores of 5 or less missing data. at presentation after blunt trauma from 2004 to 2015 were view these files, please visit ► Detailed injury patterns based on CT classification, the journal online (http:// dx. doi. included. A total of 1480 paediatric patients were analysed. type of craniotomy, cause of death and information org/ 10. 1136/ bmjopen- 2017- Primary outcome measures Patients requiring on whether intracranial pressure was monitored and 020781). neurosurgical intervention within 24 hours of hospital the actual data if measured were unavailable due to arrival and patients who died due to isolated severe Received 24 November 2017 its nature of retrospective analysis. TBI were defined as BI-NSI. The combination of systolic http://bmjopen.bmj.com/ Revised 5 February 2018 blood pressure (SBP) and heart rate (HR) on arrival, which Accepted 8 February 2018 were respectively divided into tertiles, and its correlation with BI-NSI were investigated using a multiple logistic The efficacy of intracranial pressure regression model. monitoring in paediatric patients with Results In the study cohort, 297 (20.1%) exhibited BI- severe TBI remains controversial4; however, NSI. After adjusting for sex, age category and with or intracranial hypertension is associated with without haemorrhage shock, groups with higher SBP high mortality and unfavourable neurolog- and lower HR (SBP ≥135 mm Hg; HR ≤92 bpm) were 5–9 ical outcomes. If intracranial pressure on September 23, 2021 by guest. Protected copyright. significantly associated with BI-NSI (OR 2.84, 95% CI increases after TBI, systemic blood pressure 1.68 to 4.80, P<0.001) compared with the patients with rises as a compensatory mechanism to main- normal vital signs. In age-specific analysis, hypertension tain cerebral perfusion pressure.10 Cushing’s and bradycardia were significantly associated with BI-NSI 1Advanced Emergency and triad of respiratory irregularity, hyperten- Critical Care Medical Center, in a group of 7–10 and 11–15 years of age; however, no significant association was observed in a group of 2–6 sion and bradycardia is a classic sign of intra- Okayama University Hospital, 11 Okayama, Japan years of age. cranial hypertension. It usually serves as a 2Department of Emergency Conclusions Cushing’s sign after blunt trauma was warning sign of brain herniation. Hypoten- and Critical Care Medicine, significantly associated with BI-NSI in school-age children sion in paediatric patients with severe TBI is Okayama University Graduate and young adolescents. also associated with poor outcomes due to School of Medicine, Dentistry decreased cerebral perfusion pressure.12 13 and Pharmaceutical Sciences, Okayama, Japan Although evidence is scant, as early decom- 3Department of Human Ecology, pressive surgery may be beneficial in children 14 Okayama University Graduate INTRODUCTION with severe TBI, rapid identification of those School of Environmental and Traumatic brain injury (TBI) is a critical global who require surgical intervention plays an Life Science, Okayama, Japan public health problem, given the number of important role in improving outcomes. Cush- 1 2 Correspondence to children and youth affected. Early diagnosis ing’s sign has been demonstrated to be a weak Dr Tetsuya Yumoto; and management of severe TBI is crucial to but important predictor of the requirement 3 tyumoto@ cc. okayama- u. ac. jp reduce mortality and morbidity. for urgent neurosurgical treatment in adult Yumoto T, et al. BMJ Open 2018;8:e020781. doi:10.1136/bmjopen-2017-020781 1 Open Access BMJ Open: first published as 10.1136/bmjopen-2017-020781 on 3 March 2018. Downloaded from TBI.15 However, its clinical importance in the paediatric age-specific mean arterial pressure or cerebral perfusion population has not been elucidated. We hypothesised that pressure thresholds.18 19 26 Cushing’s sign at emergency department presentation could predict severe TBI requiring immediate neurosur- Statistical analysis gical intervention (BI-NSI) in children. The purpose of Data are shown as numbers and percentages for cate- this study was to investigate the combination of systolic gorical variables, mean and SD, or median and IQRs for blood pressure (SBP) and heart rate (HR) in paediatric continuous variables depending on their distributions. patients with altered mental status on admission after TBI BI-NSI and non–BI-NSI group patients were compared and its correlation with BI-NSI. in the overall population and in the age-specific groups. Comparisons between the groups were made using the Χ2 test, Student’s t-test or Mann-Whitney U test as appropriate. METHODS We first evaluated the associations of SBP and HR with Study design and data collection BI-NSI independently using a restricted cubic spline This was a nationwide retrospective cohort study using function. We used four knots for SBP and HR to incorpo- data from the Japan Trauma Data Bank (JTDB), which rate the spline functions into multiple logistic regression represents one of the largest trauma databases in the models, which adjusted for sex, age category and with or 16 world. The JTDB was created in 2003 with the Japanese without the need for emergency thoracotomy, laparotomy Association for Acute Medicine (Committee for Clinical or transcatheter arterial embolisation (TAE) to control Care Evaluation) and the Japanese Association for the haemorrhage. We then obtained the adjusted ORs with 17 Surgery of Trauma (Trauma Surgery Committee). As their 95% CIs for each SBP and HR using the medians of of March 2016, 256 emergency and critical care centres both indicators (ie, 124 mm Hg for SBP and 105 beats/ in secondary and tertiary hospitals participated in min for HR) as our reference. Japanese trauma care and research. The registry data- Overall population and each age group were, respec- base includes patient demographics, mechanism of tively, categorised into nine groups according to each injury, vital signs on arrival, Injury Severity Score (ISS), tertile (low, normal and high) of SBP and HR to assess surgical procedures and discharge status. The Okayama the associations of the combination of SBP and HR with University Hospital ethical committee approved this BI-NSI. To determine the adjusted ORs with their 95% study (ID 1708–001). Because of the anonymous nature CIs for BI-NSI in overall population according to the cate- of the data, they waived the requirement for informed gories of the combination of SBP and HR, we developed consent. a multiple logistic regression model after adjusting for age groups (2–6 vs 7–10 vs 11–15 years old), sex and with http://bmjopen.bmj.com/ Participants and definitions or without the need for emergency thoracotomy, lapa- All trauma patients logged in the JTDB from January rotomy or TAE to control haemorrhage,15 27 with normal 2004 to December 2015 were assessed for eligibility. In SBP and normal HR group as the reference category.28 29 this study, the paediatric population was defined as chil- Age group-specific adjusted ORs and their 95% CIs were dren under 16 years of age. Children who were younger also evaluated after adjusting for sex and with or without than 2 years old were excluded because of rapid changes the need for emergency thoracotomy, laparotomy or TAE in physiology in the first 2 years of life.18 19 Patients to control haemorrhage. The Hosmer-Lemeshow test presenting with blunt trauma, who were directly trans- was used for assessing the calibration of the models. The on September 23, 2021 by guest. Protected copyright. ported from the injury location, and with Glasgow Coma Nagelkerke’s R2 value was calculated to evaluate the good- Scale (GCS) motor scores of 5 or less, which implicates ness of fit of the models. severe TBI, were included.20 Patients who arrived in A sensitivity analysis was performed that excluded cardiac arrest or with head Abbreviated Injury Scale (AIS) subjects who required emergency thoracotomy, lapa- score of 6 were excluded. Patients were also excluded if rotomy or TAE to control haemorrhage
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