Pediatric Surgery International (2021) 37:1421–1428 https://doi.org/10.1007/s00383-021-04959-2 ORIGINAL ARTICLE Traumatic brain injury in children with thoracic injury: clinical signifcance and impact on ventilatory management Caroline Baud1 · Benjamin Crulli2 · Jean‑Noël Evain3 · Clément Isola1 · Isabelle Wroblewski1 · Pierre Bouzat3 · Guillaume Mortamet1 Accepted: 29 June 2021 / Published online: 7 July 2021 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021 Abstract Purpose This study aims to describe the epidemiology and management of chest trauma in our center, and to compare patterns of mechanical ventilation in patients with or without associated moderate-to-severe traumatic brain injury (TBI). Methods All children admitted to our level-1 trauma center from February 2012 to December 2018 following chest trauma were included in this retrospective study. Results A total of 75 patients with a median age of 11 [6–13] years, with thoracic injuries were included. Most patients also had extra-thoracic injuries (n = 71, 95%) and 59 (79%) had TBI. A total of 52 patients (69%) were admitted to intensive care and 31 (41%) were mechanically ventilated. In patients requiring mechanical ventilation, there was no diference in tidal volume or positive end-expiratory pressure in patients with moderate-to-severe TBI when compared with those with no-or-mild TBI. Only one patient developed Acute Respiratory Distress Syndrome. A total of 6 patients (8%) died and all had moderate-to-severe TBI. Conclusion In this small retrospective series, most patients requiring mechanical ventilation following chest trauma had associated moderate-to-severe TBI. Mechanical ventilation to manage TBI does not seem to be associated with more acute respiratory distress syndrome occurrence. Keywords Chest trauma · Mechanical ventilation · Pulmonary contusion · Traumatic brain injury · Children Introduction Syndrome (ARDS) develops in a minority of children fol- lowing trauma but is associated with worse outcomes [5–8]. Trauma remains a leading cause of childhood mortality Clinicians are then faced with potentially opposing para- worldwide. The World Health Organization estimates that digms regarding the management of mechanical ventilation 950,000 children under the age of 18 died as a result of in such patients; while tolerating moderate hypercapnia and an injury in 2004 [1]. Between 4 and 8% of all pediatric hypoxemia may limit ventilator-induced lung injury [9], trauma victims present with thoracic injury, which although they are well-known factors worsening outcome in patients infrequent is associated with higher mortality [2–4]. These with severe TBI [10]. Finally, although the management of patients often present with associated traumatic brain injury chest trauma patients is well defned in adults [11], pediatric- (TBI), and the most commonly identifed thoracic injury specifc guidelines are lacking and current strategies for the is pulmonary contusion [2]. Acute Respiratory Distress management of chest trauma in children are mostly based upon adult protocols. * Guillaume Mortamet In the present study, we hypothesize that the presence of [email protected] a moderate-to-severe TBI associated with chest trauma leads to diferences in the management of mechanical ventilation. 1 Pediatric Intensive Care Unit, Grenoble Alpes University In this context, the aim of this study is to describe a single- Hospital, La Tronche, France center cohort of chest trauma in the pediatric population and 2 Pediatric Intensive Care Unit, Great Ormond Street Hospital to compare patterns of mechanical ventilation in patients for Children, London, UK with or without associated moderate-to-severe TBI. 3 Department of Anesthesiology and Critical Care, Grenoble Alps University Hospital, La Tronche, France Vol.:(0123456789)1 3 1422 Pediatric Surgery International (2021) 37:1421–1428 Materials and methods value set for at least one hour). The occurrence of ARDS (commonly diagnosed according to PALICC defnition [9]) Study design and patients and pneumonia (diagnosed in the context of fever, purulent tracheobronchial secretions, new or changing infltrates on This monocentric retrospective study was conducted in the the chest radiography occurring > 48 h after admission, pediatric trauma room of the Grenoble-Alps University and confrmation by positive cultures) was assessed retro- Hospital, the only level-1 pediatric trauma center in the spectively based on the fnal medical report. Pneumonia French Alps. All patients up to 16 years of age included onset was considered early when occurring between days in the TRENAU (The Northern French Alps Trauma Sys- 1 and 4 or late when occurring from day 4. Contusion was tem) registry and admitted to the trauma room from Febru- defned as any damage to the parenchyma. Finally, adher- ary 2012 to December 2018 were eligible. Patients were ence with lung-protective ventilation strategy was assessed included if they presented with chest trauma, as reported retrospectively and defned as within targets when V T was by the on-site physician or by the trauma leader in the between 6 and 8 ml/kg. frst admission report, based on clinical examination and/ Recorded outcomes included ICU and hospital length of or chest imagery. The TRENAU registry collects medical stay, duration of mechanical ventilation, Pediatric Overall Per- data from the trauma scene to the admission in the PICU/ formance Category (POPC) score [16] at hospital discharge ICU and was approved by the regional institutional review and in-hospital mortality. board (Comité d’Ethique des Centres d’Investigation Clin- In our center, we do not have any written protocol for ven- ique de l’inter-région Rhône-Alpes-Auvergne, IRB number tilatory management of patients with chest trauma and it was 5708). This manuscript adheres to the applicable STROBE based on the clinical judgement of the team in charge. Since guidelines [12]. the national recommendations on this topic were conducted by a local colleague (PB), we assume that they are well known to local physicians in charge of pediatric patients with severe Collected data trauma. Patients are usually intubated in case of 1/neurological failure with Glasgow Coma Score < 8, 2/severe hemodynamic All data were collected from electronic medical records failure not improved by initial management, and 3/respiratory (Clinisoft, General Electrics). Demographic data included failure with SpO 2 < 92% despite appropriate management, age and gender while clinical data included mechanism including low-fow oxygen therapy. A cardiac ultrasound is of injury, severity scores [Injury Severity Scores (ISS), performed at admission, as well as a complete biological test- Abbreviated Injury Score (AIS), Pediatric Trauma Score ing including Troponin. (PTS), Pediatric Risk of Mortality (PRISM)] [13–15], initial clinical assessment, radiological and laboratory Statistical analysis fndings, and management. Regarding the initial clinical assessment, respiratory failure was defned as pulse oxi- Descriptive statistical analyses were performed using SPSS metry < 90% in room air at the scene, hemodynamic failure (SPSS 26.0, Chicago, IL, USA). Tests were bilateral, and a p was defned as the need for > 40 mL/kg of fuid or continu- value < 0.05 was considered as statistically signifcant. Cat- ous infusion of vasopressors within the frst 4 h after ICU egorical variables were expressed as number (%) and com- 2 admission, and moderate-to-severe TBI was defned by a pared using chi-square test (χ ) or Fisher’s exact test (when Glasgow Coma Scale (GCS) < 13 at ICU admission. We expected frequencies were less than fve), as appropriate. The defned myocardial injury as a troponin level > 50 ng/L distribution of continuous variables was studied by frequency and/or a cardiac dysfunction on cardiac ultrasound at histogram and QQ plot, complemented by Shapiro–Wilk test admission. Therapies recorded included blood product if necessary. Continuous variables were expressed as mean transfusion, non-orthopedic surgical intervention, invasive (standard deviation, SD) or median [interquartile range, IQR] ventilation for more than 1 day, and the use of vasopres- and compared using the unpaired Student’s t test or the non- sors, neuromuscular blockers or antibiotics within the frst parametric Mann–Whitney U test, as appropriate. 24 h. The type and mode of mechanical ventilation were col- lected at admission, on days 2 and 3, as well as the follow- Results ing parameters: set FiO2, positive end-expiratory pressure Study population (PEEP), tidal volume (V T), and pressure support level. For set parameters, mean and maximum were collected, and maximum during stay was considered as the maximum During the study period, 657 patients younger than 16 years of age were admitted to our level-1 trauma center ICU and 1 3 Pediatric Surgery International (2021) 37:1421–1428 1423 recorded in the TRENAU registry. Of them, 75 (11.4%) pre- signifcant diference between days 1, 2 and 3. On day 1, 2 sented with chest trauma and were included in our analysis and 3, median FiO 2 was 40% [35–49], 30% [30–40] and 30% (Fig. 1). Baseline characteristics of participants are pre- [30–40], respectively. sented in Table 1. Their median age was 11 years [6–13] and 50 (67%) were male. Falls were the main mechanism for Outcomes trauma (n = 45, 60%). Pulmonary contusion (n = 64, 85%) pneumothorax (n = 37, 49%) and rib fracture (n = 14, 19%) Over the study period, 6 patients (8%) died, and all had were the most commonly identifed thoracic injuries. Most moderate-to-severe TBI (Table 2). Twelve (16%) and 6 patients also had associated extra-thoracic injuries (n = 71, (8%) patients developed early- and late-onset pneumonia 95%), mainly TBI (n = 59). At admission in the trauma during their ICU stay, respectively. The incidence of early- room, 26 (35%) of patients had a respiratory or hemody- onset (29 vs. 7%, p = 0.03) and late-onset pneumonia (18 namic failure. Fifty-two patients (69%) were transferred to vs. 0%, p < 0.01) was signifcantly higher in the moderate- ICU and 31 (41%) were mechanically ventilated.