Objective: To determine the scale of acute neurosurgery for severe traumatic brain injury (TBI) in childhood, and whether surgical evacuation for haematoma is achieved within four hours of presentation to an emergency department.
Methods: A 12 month audit of emergency access to all specialist neurosurgical and intensive care services in the UK. Severe TBI in a child was defined as that necessitating admission to intensive care.
Results: Of 448 children with severe head injuries, 91 (20.3%) underwent emergency neurosurgery, and 37% of these surgical patients had at least one non-reactive and dilated pupil. An acute subdural or epidural haematoma was present in 143/448 (31.9%) children, of whom 66 (46.2%) underwent surgery. Children needing surgical evacuation of haematoma were at a median distance of 29 km (interquartile range (IQR) 11.8–45.7) from their neurosurgical centre. One in four children took longer than one hour to reach hospital after injury. Once in an accident and emergency department, 41% took longer than fours hours to arrive at the regional centre. The median interval between time of accident and arrival at the surgical centre was 4.5 hours (IQR 2.23–7.73), and 79% of inter-hospital transfers were undertaken by the referring hospital rather than the regional centre. In cases where the regional centre undertook the transfer, none were completed within four hours of presentation—the median interval was 6.3 hours (IQR 5.1–8.12).
Conclusions: The system of care for severely head injured children in the UK does not achieve surgical evacuation of a significant haematoma within four hours. The recommendation to use specialist regional paediatric transfer teams delays rather than expedites the emergency service.
- CT, computed tomography
- GCS, Glasgow Coma Scale
- PICU, paediatric intensive care unit
- TBI, traumatic brain injury
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This study was supported by grants from the Paediatric Intensive Care Society, Birmingham Children’s Hospital Research Foundation and the Warwick University Research and Teaching Development Fund.
Competing interests: none declared
UK Paediatric Traumatic Brain Injury Study Steering GroupK Morris (Chair), R Appleton, M Crouchman, R Forsyth, C Hawley, M Marsh, P May, P McKinney, J Middleton, R Parslow, J Punt, T Ralph, R C Tasker.
Participating centres and investigators
Addenbrooke’s Hospital (R C Tasker), Alder Hey Children’s Hospital (R Sarginson), Antrim Hospital (A Ferguson), Beaumont Hospital, Dublin (E Keane), Birmingham Children’s Hospital (K Morris), Bristol Children’s Hospital (J Fraser), City General Hospital, Stoke (J Alexander), Derriford Hospital, Plymouth (S Ferguson), Great Ormond St Hospital (M Kenny, D Lutman), Guy’s Hospital (A Durward), Hull Royal Infirmary (H Klonin), John Radcliffe Hospital (A Shefler, C Killick), King’s College Hospital (D Prior, L Edwards, Y Egberongbe), Leeds General Infirmary (T Chater, M Darowski), Leicester Royal Infirmary (P Barry), Queen’s Medical Centre, Nottingham (P Khandelwal), James Cook University Hospital (A Robinson), Newcastle General Hospital (R Forsyth), Royal Belfast Hospital for Sick Children (B Taylor), Royal Berkshire Hospital (A Maunganidze), Royal Devon & Exeter Hospital (J Purday), Royal Hospital for Sick Children, Edinburgh (M Lo, D Simpson), Royal Hospital for Sick Children, Glasgow (P Cullen), Royal London Hospital (P Withington), Royal Manchester Children’s Hospital (D Stewart, M Samuels), Royal Preston Hospital (P Tomlin), Sandwell Hospital (J Bellin), Sheffield Children’s Hospital (T Ralph), Southampton General Hospital (C Boyles), Southern General Hospital, Glasgow (D Snaddon, A Wagstaff), St Georges Hospital (S Skellett), University Hospital of Wales (M Gajraj), Walsgrave Hospital (M Christie), Walton Centre for Neurosurgery (E Wright).