Researchers create road map for pediatric head trauma

Protocol known as PEGASUS published in The Lancet Child & Adolescent Health.

Severe traumatic brain injury is a leading cause of death and disability in children leaving 61 percent of survivors  with a lifelong disability, according to the U.S. Centers for Disease Control and Prevention and the National Institutes of Health.

Guidelines have existed to treat pediatric patients with severe head trauma, but there has been no standardized measure of their effectiveness.

Now, researchers at Harborview Medical Center in Seattle have developed such a protocol. The "Pediatric Guideline Adherence and Outcomes" protocol (PEGASUS), was tested among 199 pediatric cases at Harborview, and the results were recently published in The Lancet Child & Adolescent Health. 

PEGASUS is the first comprehensive care model for children with head trauma, said lead researcher Monica Vavilala, director of Harborview's Injury Prevention and Research Center.

"We’ve been able to provide a roadmap for what is agreed-upon as good quality care," she said. 

In an accompanying editorial, author Jose Pineda of the Washington University School of Medicine in St. Louis said the PEGASUS approach could benefit other acute-care settings.

“More studies are needed, but the PEGASUS investigators clearly took an important step towards rigorous implementation and testing of available evidence,” he said.

Vavilala and colleagues evaluated three essential parts of the PEGASUS protocol in the first 72 hours after the diagnosis of severe traumatic brain injury: Maintenance of cerebral perfusion pressure (>40 mm HG), which indicates blood flow to the brain; avoidance of hypocarbia (reduced carbon dioxide in the blood) without brain herniation; and early initiation of nutrition.

Of the 199 patients, 105 contributed data for all three key performance indicators. Adherence to at least one key performance indicator was achieved by 101 (96 percent) and 44 (42 percent) achieved adherence to all three targets.

Higher discharge survival was associated significantly with achieving adherence to cerebral perfusion pressure and nutrition targets, according to the study.

The protocol also benefited children with mild to moderate traumatic brain injury, who often deteriorate in hospital.

“Our study is, as far as we know, the first to assess both implementation and effectiveness of a hospital-wide program to improve care and outcomes for pediatric traumatic brain injury,” the researchers said.

Vavilala said further research is needed to study the PEGASUS program in other contexts, particularly in low resource healthcare settings, where most children with severe traumatic brain injury receive care.

Funding for this study came from the National Institutes of Health.

Co-authors on the study include Mary King, medical director of the Harborview Medical Center Pediatric Intensive Care Unit; Jen-Ting Yang, faculty fellow physician in the UW School of Medicine's Department of Anesthesiology and Pain Medicine; Scott Erickson, master’s student in the UW School of Public Health; Brianna Mills, research scientist with the Harborview Injury Prevention and Research Center; Rosemary Grant, sepsis care coordinator at Harborview Medical Center; Carolyn Blayney, pediatrics clinical operation manager at Harborview; Qian Qiu, research consultant with the Harborview Injury Prevention and Research Center; Randall Chesnut, UW School of Medicine professor of neurotrauma; Kenneth Jaffe, UW School of Medicine professor of rehabilitation medicine; Bryan Weiner, UW professor of global health and health services; and Brian Johnston, chief of pediatrics at Harborview.

- Bobbi Nodell, UW Medicine,, 206.543.7129

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Tags:Harborview Medical CenterHarborview Injury Prevention and Research Center

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