Inpatient outcomes in pediatric diffuse axonal injury: high mortality in severe TBI and limited impact of Grade III DAI

Purpose: This study investigates key prognostic factors influencing morbidity and mortality in pediatric diffuse axonal injury (DAI) using nationally collected data from the American College of Surgeons (ACS) Trauma Quality Program (TQP) to inform clinical practice and future research. Methods: The ACS-TQP database (2019–2021) was analyzed for pediatric DAI cases, excluding those with intracranial hemorrhages or pre-admission deaths. Demographics and clinical characteristics were compared across age groups (0–3, 4–12, 13–17), and multivariate regression identified predictors of mortality, complications, intensive care unit (ICU) stay, and ventilator duration. Results: Among 533 pediatric DAI patients, the mortality rate was 20.3%, highest in the 0–3 age group (29%) compared to 4–12 (20.8%) and 13–17 (19%) (p = 0.016). Severe traumatic brain injury (TBI) (Glasgow Coma Scale 3–8) and systolic blood pressure < 90 mm Hg were strong mortality predictors (OR 56.9, p < 0.001; OR 9.2, p < 0.001). Prolonged coma (> 24 h) increased mortality odds (OR 7.4, p = 0.018) but did not meet the adjusted threshold. Complications occurred in 16.3% of patients, with severe TBI increasing complication odds (OR 4.1, p = 0.005). ICU stay was longer with surgery (p < 0.001), and prolonged coma predicted longer ventilation (p < 0.001). Grade III DAI was not linked to worse outcomes. Conclusion: Severe TBI and hypotension were significant predictors of mortality and morbidity in pediatric DAI. Grade III DAI was not associated with worse outcomes, highlighting the need for further research to refine prognostic factors.