RESEARCH—HUMAN—CLINICAL STUDIES TOPIC

Research—Human—Clinical Studies

Jose´ Roberto Tude Melo, MD Departement of Pediatric Neurosurgery, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France; and Postgraduate Program in Medicine and Health, School of Medicine, Federal University of Bahia, Bahia, Brazil

Federico Di Rocco, MD Departement of Pediatric Neurosurgery, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Ste´phane Blanot, MD Pediatric Surgical Critical Care Unit and Anesthesiology, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Jamary Oliveira-Filho, MD, PhD Postgraduate Program in Medicine and Health, School of Medicine, Federal University of Bahia, Bahia, Brazil

Thomas Roujeau, MD Departement of Pediatric Neurosurgery, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Christian Sainte-Rose, MD Departement of Pediatric Neurosurgery, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Caroline Duracher, MD Pediatric Surgical Critical Care Unit and Anesthesiology, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Antonio Vecchione, MD Pediatric Surgical Critical Care Unit and Anesthesiology, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale BACKGROUND: Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to improve outcome. OBJECTIVE: To identify the main predictors of mortality and to propose a grading scale to measure the risk of death. METHODS: This retrospective study was based on medical records of children with severe traumatic brain injury who were hospitalized at a level I pediatric trauma center between January 2000 and December 2005. Multiple logistic regression analysis was done to identify independent factors related to mortality. A receiver-operating characteristics curve was performed to verify the accuracy of the multiple logistic regression, and associations that increased mortality were verified. RESULTS: We identified 315 children with severe head injury. Median Glasgow Coma Scale score was 6, and median Pediatric Trauma Score was 4. Global mortality rate was 30%, and deaths occurred despite adequate medical management within the first 48 hours in 79% of the patients. Age , 2 years (P = .02), Glasgow Coma Scale # 5 (P , 1025), accidental hypothermia (P = .0002), hyperglycemia (P = .0003), and coagulation disorders (P = .02) were all independent factors predicting mortality. A prognostic scale ranging from 0 to 6 that included these independent factors was then calculated for each patient and resulted in mortality rates ranging from 1% with a score of 6 to 100% with a score of 0. CONCLUSION: Independent and modifiable mortality predictors could be identified and used for a new grading scale correlated with the risk of mortality in pediatric traumatic brain injury. KEY WORDS: Craniocerebral trauma, Mortality, Pediatric, Prognosis Neurosurgery 67:1542–1547, 2010

DOI: 10.1227/NEU.0b013e3181fa7049

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Philippe Meyer, MD Pediatric Surgical Critical Care Unit and Anesthesiology, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France

Michel Zerah, MD Departement of Pediatric Neurosurgery, Hoˆpital Necker-Enfants Malades, Assistance Publique Hoˆpitaux de Paris–France, Universite´ Descartes Paris 5, Paris, France Reprint requests: Jose´ Roberto Tude Melo, MD, Alameda dos Jasmins 200 702 B Cidade Jardim, CEP 40 296 200, Salvador da Bahia, Brazil. E-mail: [email protected] Received, August 5, 2009. Accepted, June 4, 2010. Copyright ª 2010 by the Congress of Neurological Surgeons

T

raumatic brain injury (TBI) is recognized as a major public health concern in many countries around the world.1,2 Although the best way to decrease mortality is to prevent accidents, limiting systemic sources of secondary brain lesions is critical to improve outcome.3,4 Many prognostic factors of mortality and poor outcome have been described,5,6 but variable

ABBREVIATIONS: CCT, cranial computed tomography; CI, confidence interval; GCS, Glasgow Coma Scale; ICP, intracranial pressure; PT, prothrombin time; PTS, Pediatric Trauma Score; SaO2, arterial oxygen saturation; TBI, traumatic brain injury

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inclusion criteria, heterogeneous initial management, and variable collection of clinical and biological data have precluded definitive conclusions. The goals of this study were to report our experience of severe TBI resulting from accidental trauma in a pediatric population treated with standardized protocols and to validate systemic factors like hypoxia, arterial hypotension, hypothermia, hyperglycemia, and coagulation disorders as valuable predictive factors of mortality in this population. The secondary aim was to design a new grading scale using independent factors identified in this study to predict mortality in children with severe TBI. This grading scale could be further validated in a multicenter study.

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MORTALITY IN HEAD-INJURED CHILDREN

MATERIALS AND METHODS This descriptive and retrospective cross-sectional study is based on the analysis of prospectively collected data of children , 17 years of age who presented with a severe TBI defined by an initial Glasgow Coma Scale (GCS) # 8. We reviewed the medical records of all children admitted to the emergency room of the Hoˆpital Necker-Enfants Malades (Paris, France) between January 2000 and December 2005 (6 years). Children with a nonaccidental injury or with initial GCS . 8 were excluded from analysis. All these children were managed at the scene of the accident by a medical crew of the Service d’Aide Me´dicale d’Urgence, transported to our trauma center, and benefited from standardized treatment protocol. All children with a GCS # 8 were mechanically ventilated with continuous end-tidal CO2 and arterial oxygen saturation (SaO2) monitoring and deeply sedated with a combination of intravenous benzodiazepine and morphine. Arterial and central venous catheters were systematically inserted on admission. Serial blood samples for arterial blood gazes, ionogram, blood glucose, and hemostasis were drawn within the first 20 minutes after hospital admission in all patients and at least every 6 hours during the acute phase, according to the French National Guidelines for emergency management of severe head injuries in all cases.7-9 Data were collected for age, gender, mechanism of trauma, clinical presentation on arrival, and laboratory and radiological examinations results. After minimal in-hospital stabilization and invasive monitoring placement (central venous and arterial line catheters), whole-body computed tomography scan was performed in all children. The results of initial cranial computed tomography (CCT) and whole-body computed tomography scan examinations were recorded, as well as the modality of neurosurgical treatment. We considered the following initial clinical and biological exams on admission as potential predictive factors of increased mortality, according to the medical literature: ideal oxygen saturation, defined by a measured SaO2 $ 97% in mechanically ventilated patients at hospital admission10; hypotension, defined as a systolic arterial blood pressure recorded through an arterial catheter 10% less than normal values according to age group based on the American Heart Association criteria11; accidental hypothermia, considered in children with a body temperature , 35C12 identified in the emergency room; blood glucose levels and prothrombin time (PT) at admission (blood glucose levels $ 11.1 mmol/L [200 mg/dL] were considered abnormal [hyperglycemia]13 and PT . 2 times the control value for laboratory was classified as a coagulation disturbance14,15); and GCS and Pediatric Trauma Score (PTS) at hospital admission (We classified patients with GCS # 5 and those with PTS # 3 as having the most severe trauma, according to the literature).4,16,17 Intraparenchymal pressure transducers (Codman) were inserted as soon as possible, usually within the first 3 hours, after clinical stabilization and CCT scan examination, except in those patients with initial GCS of 3 without brainstem reflex and with severe coagulation disorders, for whom the surgical risk of transducer insertion was considered too high. Statistical analysis was performed with SSPS version 9.0 for Windows (SPSS Inc, Chicago, Illinois). For data analysis, all quantitative variables were expressed as mean 6 SD. We determined the statistical significance of trends by using the Mantel-Haenszel x2 test (1 df), and for the analyses, we used the 95% confidence interval (CI). The univariate analysis was done by analysis of variance. A multiple logistic regression analysis was done to show independent factors that influenced mortality. After determination of the mortality related factors, a receiver-operating

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characteristics curve was performed to verify the accuracy of the multiple logistic regression that showed 93% of adjusting values. Associations of factors that may increase mortality rates were analyzed, and a new scale was proposed to predict mortality in children with severe head trauma on hospital admission. The scale was retrospectively calculated for each child included in our sample to verify rates of mortality predicted by the score. This cooperative descriptive international study was conducted in agreement with French law requirements (anonymous treatment of collected data, institutional board review approval, and no written consent required) and approved by the Brazilian Research Ethics Committee under registration No. 06/07.

RESULTS We evaluated 315 medical files of children , 17 years of age who were victims of accidental severe TBI. Mean age was 7 6 4.4 years (range, 1 month to 17 years) with a male predominance (68%) mainly after 3 years of age. The most frequent mechanisms of injuries were road traffic accidents (58%, 183 of 315), with pedestrians struck by moving vehicles representing 63% of the cases (116 of 183). Home accidents were identified in 36% (115 of 315) of the cases, with falls from windows in 60% (69 of 115) of them. Scene management was in accordance with recommended protocols in 100% of the cases. No children had a previous history of diabetes mellitus or coagulation disorder. Brain swelling (hypodense brain with reduced or absent cerebrospinal fluid spaces but without extravascular hyperdense blood with a disappearance of the contrast between the white and the gray matter; 54%), skull fracture (47%), and diffuse brain contusion (41%) were the most important findings on CCT scans. Isolated epidural or subdural hematomas were noted in only 3% and 1%, respectively. Only 9% of the patients had a normal admission CCT scan. Whole-body computed tomography scan identified multiple traumas in 79% of cases. The most frequent associated injuries were lung contusion and pleural effusion (62%); bones fractures mainly in the upper limbs, femoral shaft, or pelvic ring (32%); facial fractures and lacerations (29%); abdominal solid organ lesions (20%); and spinal cord injuries (5%). About 67% of TBI patients with multiple traumas had lesions in more than 1 organ. Emergency neurosurgical treatment included surgical evacuation of a compressive epidural/subdural or intraparenchymal hematoma (13 of 315, 4%), combined intracranial pressure (ICP) monitoring insertion and hematoma evacuation (25 of 315, 8%), and decompressive craniectomy (4 of 315, 1%). An intraparenchymal pressure transducer for continuous ICP monitoring was inserted in 196 patients (62%). Medical treatment was used in the Pediatric Intensive Care Unit without any preceding neurosurgical procedure in 81 patients (26%). Among these 81 patients, 57% (46 of 81) had a GCS of 3 with absent brainstem reflexes on hospital admission, 36% (29 of 81) had severe coagulation disorders, 7% (6 of 81) had hemodynamic instability, and 64% (52 of 81) died within the first 24 hours after trauma.

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TUDE MELO ET AL

The global mortality rate was 30% (95 of 315) and was higher in children , 2 years of age (42% vs 27%; P = .02). Death occurred within the first week after trauma in 97% (92 of 95) of the cases and within the first 48 hours in 79% (73 of 92). Mortality predictors detected by univariate analysis are presented in Table 1. The presence of clinical factors on admission such as inadequate SaO2 or hypotension increased the incidence of death 3-fold and hypothermia 4-fold. Regarding biochemical markers, hyperglycemia and severe coagulation disorders increased the risk of death 5 times (Table 1). Multiple logistic regression isolated accidental hypothermia (odds ratio = 8.49; 95% CI = 2.75-26.19; P = .0002), hyperglycemia (odds ratio = 6.14; 95% CI = 2.25– 16.73; P = .0003), coagulation disorders (odds ratio = 3.10; 95% CI = 1.05-9.18; P = .02), and GCS # 5 (odds ratio = 11; 95% CI = 3.74-32.33; P , 1025) as independent factors of increased mortality (Table 2). Associated severe traumatic lesions were not significant predictors of mortality in the multiple logistic regression (Table 2).

TABLE 2. Multiple Logistic Regression (Adjusted for Age) to Identify Independent Mortality Prognostic Factors Related to Death in 315 Children with Severe Head Injury Between January 2000 and December 2005 in Paris, Francea Clinical Characteristics SaO2, % $ 97 , 97 SAP satisfactory Yes No Body temperature, C $ 35 , 35 Blood glucose, mmol/L , 11.1 $ 11.1 PT . 2 times control No Yes GCS .5 #5 PTS .3 #3 Multiple trauma No Yes

TABLE 1. Univariate Analysis of Incidence and Relative Risk of Death in 315 Children With Severe Head Trauma Admitted to the Emergency Room from January 2000 to December 2005 in Paris, Francea Clinical Characteristics

n (%)

Incidence of Death, n (%)

Odds Ratio

95% CI (Mantel-Haenszel Test)

95% CI

1.00 1.67

... 0.47-5.86

1.00 0.69

... 0.20-2.36

1.00 8.49

... 2.75-26.19

1.00 6.14

... 2.25-16.73

1.00 3.10

... 1.05-9.18

1.00 11.00

... 3.74-32.33

1.00 1.31

... 0.46-3.74

1.00 1.11

... 0.32-3.89

a

b

SaO2, % $ 97 239 (80) , 97 60 (20) SAPb Normal 242 (77) Abnormal 71 (23) Body temperature, C $ 35 239 (83) , 35 48 (17) Blood glucose level, mmol/Lb , 11.1 210 (72) $ 11.1 83 (28) PT . 2 times controlb No 212 (73) Yes 78 (27) GCSb .5 170 (56) #5 136 (44) PTSb .3 136 (50) #3 135 (50) Multiple traumab No 67 (21) Yes 248 (79)

Odds Ratio

48 (20) 36 (60)

1 2.99

... 2.16-4.14

48 (20) 47 (66)

1 3.34

... 2.47-4.52

38 (16) 32 (67)

1 4.19

... 2.94-5.97

26 (12) 51 (61)

1 4.96

... 3.33-7.39

26 (12) 48 (61)

1 5.02

... 3.36-7.49

10 (6) 81 (60)

1 10.13

... 5.46-18.77

15 (11) 67 (50)

1 4.50

... 2.71-7.47

12 (18) 83 (33)

1 1.87

... 1.09-3.21

a

CI, confidence interval; GCS, Glasgow Coma Scale; PT, prothrombin time; PTS, Pediatric Trauma Score; SaO2, arterial oxygen saturation; SAP, systolic arterial blood pressure. b P , .0001.

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CI, confidence interval; GCS, Glasgow Coma Scale; PT, prothrombin time; PTS, Pediatric Trauma Score; Sao2, arterial oxygen saturation; SAP, systolic arterial blood pressure.

Starting from multiple logistic regression to try to predict the risk of mortality, these criteria were used to design a new grading scale to be applied in children with severe head injury. Each item (age, GCS, body temperature, blood glucose levels, and PT) was coded with reference to its defined threshold values, and individual codes were summed to obtain a score between 0 and 6 (Table 3). The score was retrospectively calculated for each child, and the mortality rate was calculated for each value of the score. An inverse correlation between calculated score and rate of mortality was found with 1% mortality for a score 6 and 100% for a score 0 (Figure).

DISCUSSION In the present study, a large and homogeneous series of children with severe TBI was analyzed. From this analysis, we identified independent factors predicting mortality that could be used to design a predictive grading scale of mortality in further studies. Epidemiological data in our population did not differ significantly from those previously reported in the pediatric trauma literature. Road traffic accidents in older children and falls

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TABLE 3. Proposed Scale to Be Applied During the First Hours After Hospital Admission in Children With Severe Head Trauma to Determine the Severity of Traumatic Brain injury and Risk of Death: The Necker Cranial Injury Scale Factors Included Age group, y #2 .2 GCS #5 .5 Temperature, C , 35 $ 35 Blood glucose levels, mmol/L $ 11.1 , 11.1 Prothrombin time . 2 times control Yes No a

Scorea 0 1 0 2 0 1 0 1 0 1

Score extremes: 0 and 6.

from heights in preschool-aged children are the main mechanisms encountered.4,18 A male prevalence, which could be found within the first year of life in some series,2 and a mean age of 7 6 4.4 years with a classic age distribution were noted.19 Patients , 2 years of age were at increased risk of epidural/subdural hematoma, initial hypotension, and mortality as previously described.4 This increased risk of severe brain injuries in young victims has

FIGURE. Mortality rate according each score of the Necker Cranial Injury Scale in 315 children with severe head injury admitted to the emergency room of the Hoˆpital Necker-Enfants Malades (Paris, France) between 2000 and 2005.

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been previously underlined20 and may be related to an impaired vascular regulation in immature brain and limited adaptation capabilities to acute blood losses. Regarding intracranial lesions, diffuse edema/brain swelling (54%), skull fractures (47%), and brain contusions (41%) were the most frequent findings in CCT scans, which is in accordance with other reports.21,22 In these comatose children, except for children , 2 years of age, diffuse brain lesions were much more frequent than focal brain hematomas and acute epidural/subdural hematomas requiring emergency craniotomy and surgical evacuation. This prevalence of diffuse lesions, a characteristic ofpediatric severe TBI,17 explains the low incidence (, 13%) of emergency neurosurgical procedures, except ICP transducer insertion, performed in these patients. ICP transducers for continuous monitoring, used in most children (70%), represented the most frequent neurosurgical procedure performed within the first 12 hours after admission. As in other series,23,24 multiple associated injuries, mainly chest lesions, were noted in nearly 70% of the patients. These severe chest lesions could put children at risk for respiratory distress and hypoxemia resulting in secondary brain lesions. However, multiple traumas could not be identified as an independent risk factor of mortality in the present study. In children with severe TBI, rapid development of secondary brain lesions is a major issue. The goal of aggressive medical management that could be initiated efficiently at the scene of the accident was to decrease the incidence of secondary cerebral insults of systemic origin such as hypotension, hypoxia, hyperglycemia, and hypercapnia.10,17,25,26 In previous reports evaluating the influence of systemic factors on mortality, wide variations could be observed in medical management protocols used at the early phase after trauma. This could add a major bias that was avoided in this study because all children were managed according to the same strict medical protocol, with early controlled mechanical ventilation, hemodynamic stabilization, and glucose-free intravenous infusion. However, despite adapted mechanical ventilation and adequate volume expansion, 20% of our patients remained hypoxic, and 23% had low systolic arterial blood pressure on arrival. As in other reports,27-29 patients with persistent hypoxemia and hypotension more frequently suffered severe pulmonary lesions, heavy blood losses from multiple/open fractures, and abdominal injuries such as liver and spleen lacerations. Most patients did not respond to an increased level of critical care, and the incidence of deaths was 3 times higher in this group compared with the remaining population. Independent predictors of mortality could be isolated from the multivariate analysis. Body temperature , 35C on arrival was an independent factor predicting mortality, with a 4-fold increased risk of mortality. Accidental spontaneous hypothermia has been described as a predictive factor of poor outcome in head-injured patients.12,25 It could reflect severe multiorgan failure caused by hemorrhagic shock and resulting peripheral vasoconstriction and tissue hypoperfusion or dysfunction of autonomic core temperature regulation with extensive brain damage.12,25,30

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Hyperglycemia was a marker of severe brain injury and an independent predictor of mortality. The risk of death was increased 5-fold in children with a blood glucose $ 11.1 mmol/L (200 mg/dL). The influence of uncontrolled hyperglycemia on poor outcome in severely ill patients, especially in those with TBI,31-33 is well described. However, there is no clinical consensus regarding its precise pathophysiology or the level of blood glucose to be considered harmful, and the benefits of actively treating hyperglycemia in head-injured children are still being debated.31-34 Coagulation disorders, namely PT more than twice the laboratory reference, were isolated as independent predictors of mortality. They could be noted in children with isolated severe TBI without heavy bleeding lesions. This correlation between TBI and coagulation disorders has been extensively described35,36 and could directly result from extensive brain tissue destruction. Previously described grading scales such as the GCS and PTS have been identified as predictive of bad outcome.16,17 In a previous series from our center, GCS # 5 and PTS # 3 were identified as predictors of increased mortality and poor outcome in children with severe head injury.4 The same correlation between GCS # 5 and mortality was found in the present series, with a 10-fold increased risk of death in patients with a GCS # 5. On the contrary, PTS, which is widely influenced by other variables, namely patient age through its weight component and associated lesions, was not an independent predictor of mortality. A global mortality rate of 30% was noted in this study. This is slightly higher than previously reported at our institution (22%).4 This high mortality rate could be explained by the fact that all children, except those with nonaccidental trauma, presenting at the scene with a GCS # 8, successfully resuscitated at the scene, and transferred to our center were included in the analysis regardless of their clinical condition on arrival. In nonsurvivors, death occurred within the first hours after admission in most cases despite early aggressive medical management and reflected the severity of primary brain injuries and associated lesions. This high proportion of very early deaths has been noted by others37 and supports the role of accident prevention as the primary efficient means to limit early mortality in children with head trauma. Hypoxemia, hypotension, hypothermia, and hyperglycemia are clearly the sources of secondary brain insults of systemic origin that could be prevented, or at least limited, by early adequate medical management. This medical management should be initiated as soon as possible and includes early airway control with endotracheal intubation and adequate ventilation, prompt hemodynamic stabilization, prevention of accidental hypothermia, and exclusion of glucose and hypo-osmotic intravenous solutions. When present on admission, these systemic factors of secondary brain insults, alone or associated, significantly increase the risk of mortality. Defining a simple and practical scale to predict adequately and reproducibly the risks of mortality in head-injured children is difficult. In most studies, prediction of death has been based on a multifactorial analysis of combined parameters or on a correlation between a single biochemical marker and bad outcome.22,38

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The reliability of these scales for predicting death, specifically in children with TBI, could be questioned. Using our independent predictors of mortality isolated by multiple logistic regression, we designed a practical scale, the Necker Cranial Injury Scale, that can be used easily and efficiently to predict mortality in children with severe TBI. Age stratification was simplified considering that children # 2 years of age had the highest risks of severe injuries and mortality. Clinically relevant parameters included GCS # 5 at admission, based on a predefined threshold value for bad outcome, and body temperature. Biological parameters included blood glucose levels $ 11.1 mmol/L and PT in excess of twice the laboratory reference on admission. To confirm the efficiency of the Necker Cranial Injury Scale for predicting mortality in our population, it was retrospectively calculated for each patient and correlated with mortality. An inverse correlation between calculated scores and incidence of death was found in our population. Although this scale has been applied only in a specific sample of pediatric TBI children and could reflect a regional practice, it is easy to use and could be externally validated in other sample populations. Further prospective evaluation in large multicenter studies is needed to confirm its reliability in a general pediatric population. Severe TBI still carries a high risk of early mortality in children. One advantage of the Necker Cranial Injury Scale is that several modifiable outcome predictors were identified, including hypothermia, coagulopathy, and hyperglycemia, which could be separately tested as therapeutic targets in clinical trials of pediatric TBI. Clinical and biological markers of mortality can be identified on admission. The applicability of this scale to other pediatric trauma populations remains to be demonstrated by further validation. Disclosure This work was supported by Coordenacxa˜o de Aperfeicxoamento de Pessoal de Nı´vel Superior–Exchange Program for PhD studies. The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

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VOLUME 67 | NUMBER 6 | DECEMBER 2010 | 1547

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Mortality in Children With Severe Head Trauma: Predictive Factors and Proposal for a New Predictive Scale.

Traumatic brain injury is a public health problem around the world, and recognition of systemic sources of secondary brain lesions is crucial to impro...
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