Assessment of Non-Routine Events and Significant Physiological Disturbances during Emergency Department Evaluation after Pediatric Head Trauma

Abstract

Outcomes following pediatric traumatic brain injury (TBI) are dependent on initial injury severity and prevention of secondary injury. Hypoxia, hypotension, and hyperventilation following TBI are associated with increased mortality. The purpose of this study was to determine the association of non-routine events (NREs) during the initial resuscitation phase with these physiological disturbances. We conducted a video review of pediatric trauma resuscitations of patients with suspected TBI and Glasgow Coma Scale (GCS) scores <13. NREs were rated as "momentary" if task progression was delayed by <1 min and "moderate" if delayed by >1 min. Vital sign monitor data were used to identify periods of significant physiological disturbances. We calculated the association between the rate of overall and moderate NREs per case and the proportion of cases with abnormal vital signs using multi-variate linear regression, controlling for GCS score and need for intubation. Among 26 resuscitations, 604 NREs were identified with a median of 23 (interquartile range [IQR] 17-27.8, range 5-44) per case. Moderate delay NREs occurred in 19 resuscitations (n = 32, median 1 NRE/resuscitation, IQR 0.3-1, range 0-5). Oxygen desaturation and respiratory depression were associated with a greater rate of moderate NREs (p = 0.008, p < 0.001, respectively). We observed no association between duration of hypotension, desaturation, and respiratory depression and overall NRE rate. NREs are common in the initial resuscitation of children with moderate to severe TBI. Episodes of hypoxia and respiratory depression are associated with NREs that cause a moderate delay in task progression. Conformance with resuscitation guidelines is needed to prevent physiological events associated with adverse outcomes following pediatric TBI.

Keywords: brain injuries; errors; medical; pediatrics; protocol compliance; traumatic; vital signs.