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Traumatic Brain Injury and Infectious Encephalopathy in Children From Four Resource-Limited Settings in Africa*

Fink, Ericka L. MD, MS1,2; von Saint Andre-von Arnim, Amelie MD3; Kumar, Rashmi MD4; Wilson, Patrick T. MD, MPH5; Bacha, Tigist MD, MPH6; Aklilu, Abenezer Tirsit MD, FCS (ECSA)7; Teklemariam, Tsegazeab Laeke MD, FCS (ECSA)7; Hooli, Shubhada MD, MPH8; Tuyisenge, Lisine MD, MMED9; Otupiri, Easmon MPH, PhD10; Fabio, Anthony PhD, MPH11; Gianakas, John BS11; Kochanek, Patrick M. MD1,2; Angus, Derek C. MD, MPH, FRCP12,13; Tasker, Robert C. MA, MD, FRCP14; for the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network, PALISI Global Health Subgroup, and Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment (PANGEA) Investigators

Pediatric Critical Care Medicine: July 2018 - Volume 19 - Issue 7 - p 649-657
doi: 10.1097/PCC.0000000000001554
Neurocritical Care
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Objectives: To assess the frequency, interventions, and outcomes of children presenting with traumatic brain injury or infectious encephalopathy in low-resource settings.

Design: Prospective study.

Setting: Four hospitals in Sub-Saharan Africa.

Patients: Children age 1 day to 17 years old evaluated at the hospital with traumatic brain injury or infectious encephalopathy.

Interventions: None.

Measurements and Main Results: We evaluated the frequency and outcomes of children presenting consecutively over 4 weeks to any hospital department with traumatic brain injury or infectious encephalopathy. Pediatric Cerebral Performance Category score was assessed pre morbidity and at hospital discharge. Overall, 130 children were studied (58 [45%] had traumatic brain injury) from hospitals in Ethiopia (n = 51), Kenya (n = 50), Rwanda (n = 20), and Ghana (n = 7). Forty-six percent had no prehospital care, and 64% required interhospital transport over 18 km (1–521 km). On comparing traumatic brain injury with infectious encephalopathy, there was no difference in presentation with altered mental state (80% vs 82%), but a greater proportion of traumatic brain injury cases had loss of consciousness (80% vs 53%; p = 0.004). Traumatic brain injury patients were older (median [range], 120 mo [6–204 mo] vs 13 mo [0.3–204 mo]), p value of less than 0.001, and more likely male (73% vs 51%), p value of less than 0.01. In 78% of infectious encephalopathy cases, cause was unknown. More infectious encephalopathy cases had a seizure (69% vs 12%; p < 0.001). In regard to outcome, infectious encephalopathy versus traumatic brain injury: hospital lengths of stay were longer for infectious encephalopathy (8 d [2–30 d] vs 4 d [1–36 d]; p = 0.003), discharge rate to home, or for inpatient rehabilitation, or death differed between infectious encephalopathy (85%, 1%, and 13%) and traumatic brain injury (79%, 12%, and 1%), respectively, p value equals to 0.044. There was no difference in the proportion of children surviving with normal or mild disability (73% traumatic brain injury vs 79% infectious encephalopathy; p = 0.526).

Conclusions: The epidemiology and outcomes of pediatric traumatic brain injury and infectious encephalopathy varied by center and disease. To improve outcomes of these conditions in low-resource setting, focus should be on neurocritical care protocols for pre-hospital, hospital, and rehabilitative care.

1Division of Pediatric Critical Care, Department of Critical Care Medicine, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA.

2Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.

2Department of Pediatrics, University of Washington and Seattle Children’s Hospital, Seattle, WA.

3Department of Paediatrics & Child Health, University of Nairobi, Kenyatta Hospital, Nairobi, Kenya.

4Division of Pediatric Critical Care Medicine, Department of Pediatrics, Columbia University Medical Center, New York, NY.

5Department of Pediatrics, Addis Ababa University, Addis Ababa, Ethiopia.

6Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia.

7Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX.

8Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda.

9Department of Community Health, School of Public Health, Kwame Nkrumah University of Science & Technology, Kumas, Ghana.

10Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA.

11Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

12Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.

13Departments of Neurology and Anaesthesia (Pediatrics), Harvard Medical School and Boston Children’s Hospital, Boston, MA.

*See also p. 680.

Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Executive committee are as follows: Ira Cheifetz, MD, Duke Children’s (Chair); Neal Thomas, MD, Penn State/Hershey Children’s (Vice-Chair); Ann Thompson, MD, Pittsburgh Children’s (Past-Chair); Martha A.Q. Curley, RN, PhD, University of Pennsylvania; Philippe Jouvet, MD, CHU Sainte-Justine; Barry Markovitz, MD, MPH, Children's Hospital of Los Angeles (Scientific Committee Chair); Akira Nishisaki, MD, Children’s Hospital of Philadelphia; Marissa Tucci, MD, CHU Sainte-Justine; Scott Watson, MD, Seattle Children’s; and Doug Willson, MD, Virginia Commonwealth University. PALISI Global Health Subgroup and Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment (PANGEA) Investigators are included as authors.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Drs. Fink’s, Bacha’s, and Kochanek’s institutions received funding from the Laerdal Foundation. Dr. Kumar received support for article research from a Laerdal grant. Dr. Wilson’s institution received funding from the University of Pittsburgh. Dr. Kochanek disclosed that he holds several patents/provisional patents in the field of acute brain injury, and his research is funded by the National Institutes of Health and the U.S. Department of Defense (although this study was not supported by those grants nor are the patents relevant to the current study); he received funding from the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies as Editor-in-Chief of Pediatric Critical Care Medicine; and he has served as an expert witness on a number of cases in the field of neurocritical care and resuscitation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: finkel@ccm.upmc.edu

Copyright © 2018 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies