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Severely Elevated Blood Pressure and Early Mortality in Children with Traumatic Brain Injuries: The Neglected End of the Spectrum
Lucas Neff, MD1, Matthew Borgman, MD2,3, Jeremy Cannon, MD, MS4, Nathan Kuppermann, MD, MPH5, Austin Johnson, MD, PhD5. 1Emory University, Atlanta, GA, USA, 2San Antonio Military Medical Center, Fort Sam Houston, Texas, USA, 3Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA, 4Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA, 5University of California Davis Medical Center, Sacramento, CA, USA.

Background: To determine if age-adjusted hypertension in children suffering from severe TBI is associated with mortality.

Methods: This was a retrospective analysis of the Department of Defense Trauma Registry from 2001-2013 of patients <18yrs with severe TBIs defined as head Abbreviated Injury Severity (AIS) scores of ≥3. Of 4,990 children identified, 740 met criteria for analysis. Hypertension was defined as moderate for systolic blood pressures (SBP) between the 95th-99th percentile for age and gender and severe if >99th percentile. Hypotension was defined as SBP<90 mmHg or <70mmHg+(2 x age) for children ≤10yrs. Multivariable logistic regression (MVLR) and Cox regression was performed to determine if blood pressure categories were associated with mortality. The primary outcomes were 24-hour and in-hospital mortality.

Results: 50 patients (6.8%) were hypotensive upon arrival to the ED, 385(52.0%) were normotensive, 115(15.5%) had moderate hypertension, and 190(25.7%) had severe hypertension. Compared to normotensive patients, patients with moderate and severe hypertension had a similar injury severity scores, AIS head scores, and frequencies of neurosurgical procedures. MVLR demonstrated that hypotension (OR 2.85, 95CI 1.26-6.47) and severe hypertension (OR 2.58, 95CI 1.32-5.03) were associated with increased 24hr mortality. Using Cox regression, neither hypotension (Hazard Ratio (HR) 1.52, 95CI 0.74-3.11) nor severe hypertension (HR 1.65, 95CI 0.65-2.30) was associated with time to mortality after excluding early deaths before 24hrs.

Conclusions: Pediatric age-adjusted hypertension is frequent after severe TBI. Severe hypertension is strongly associated with 24-hour mortality. Pediatric age-adjusted blood pressure needs to be further evaluated as a critical marker of early mortality.

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