Institutional-based cross-sectional study was conducted from May 16 to June 15, 2022 G.C.

This study was carried out in Comprehensive Specialized Hospitals of the Amhara National Regional State in Ethiopia. Amhara National regional state is one federal republics of Ethiopia with an approximate land area of 170000 square kilometers. ⁴¹ The territory is divided into 12 administrative zones, three city administrations, and 83 districts. The Amhara National Regional Health Bureau's Annual Performance Report shows the region has 81 Hospitals, 858 Health centers, and 3560 Health posts. Among Hospitals eight of them are Comprehensive Specialized Hospital these are University of Gondar, Dessie, Felege-Hiwot, Tibebe-Ghion, Debre-Markos, Waldiy, Debre Tabor, and Debebirhan Comprehensive Specialized Hospital which are serve for population within the region. ⁴² These Hospitals provide surgical, medical, pediatric, maternal, and other types of care to their patients. These hospitals have specialty units for cardiology, respiratory, neurology, dermatology, and sexually transmitted diseases, as well as gastroenterology, infectious diseases, orthopedics, gynecology and obstetrics, hematology, and intensive care units. Five Comprehensive Specialized Hospitals was chosen by simple random lottery methods from a total of eight Comprehensive Specialized Hospitals those are University of Gondar, Felege-Hiwot, Tibebe-Ghion, Debre-Markos, and Debre-Berhan Compressive Specialized Hospitals.

To assess the outcome of traumatic brain injury and its associated factors among pediatrics patients treated in Amhara National Regional State Comprehensive Specialized Hospitals, Ethiopia 2022.

Specific objectives

To determine the outcome of traumatic brain injury among pediatrics patients treated in Amhara National Regional State Comprehensive Specialized Hospitals, Ethiopia 2022.

To identify the factors associated with outcome of traumatic brain injury among pediatrics patients treated in Amhara National Regional State Comprehensive Specialized Hospitals, Ethiopia 2022.

From January 1, 2019 to December 30, 2021 G.C, the total estimated number of TBI pediatric patients who visited at selected Amhara National Regional State Comprehensive Specialized Hospitals, Ethiopia was 3,384. Our study participants were chosen by using a systematic random sampling technique after proportional allocation for each selected hospital at every k interval: K=N/n= 3,384/423, K=8. The first MRN of study participants was identified from each hospital's registry books to select sampled study participants during the study period, and then every k patient chart was selected until reached to the desired sample size and the first participant was chosen by lottery methods. As a result, the diagram below depicts how study participants were chosen, with proportional allocation from each hospital (See Figure 1).

Figure 1. Sampling procedure for the outcome of TBI among pediatrics TBI who vested in Amhara National Regional State CSHs from January 1,2019 to December 30,2021.

Pediatrics age patients: age of younger than 18 years old .^{22, 43, 44}

Glasgow coma scale: It is Generated Clinical Standards that objectively measure a patient's neurological status based on their Motor Response graded out of 6, Eye Opening graded out of 4, Verbal Response graded out of 5, and total out of 15 .⁴⁵

Severity of traumatic brain injury: Mild, moderate, and severe traumatic brain injuries are classified as GCS 13-15, 9-12, and 3-8, respectively ¹¹

Glasgow outcome scale: is a global scale for measuring functional outcome in patients with traumatic brain injury that rates patient status on a five-point : Dead, vegetative state, severe disability, moderate disability, and good recovery . ^{47, 48}

Outcome of TBI : Based on the Glasco outcome scale at the time of discharge, which is unfavorable outcome (GOS 1 - 3) and favorable outcome (GOS 4 and 5). ^{18, 43, 44}

Additional injury: when there is more than one body system involved in the injury.⁴⁹

Hypothermia and Hyperthermia: by axillary measurement hypothermia < 36.5°C and hyperthermic >37.5°C. ⁵⁰

Hypoxia: is defined as inadequate oxygen in tissues for normal cell and organ function. It can happen even when circulation is normal not or occurs when Sap02 < 90 %. ⁵¹

Hypertension and Hypotension: considered as based on with respective age and sex of pediatrics population ≥95th percentile and below the 5th percentile respectively.⁵²

Hyperglycemia and Hypoglycemia: consideration of random blood glucose on admission >200mg/dl and <70 mg/dl respectively⁴⁰

The outcome and other explanatory data of traumatic brain injury in children were collected by using data extraction tools that were developed aftera deeply review of different literature. ^{13, 16, 17, 23, 28, 50, 51}.Data were collected from patient charts and medical records of sampled study participants after obtaining MRN from the hospital registration logbooks. Five BSC nurses and two MSC nurse supervisors with prior data collection experience participated in data collection procedures. Five parts of the data extraction check list were used to assess all important variables. These are sociodemographic variables, pattern of injury related variables, clinical and management related variables, time-related variables, and traumatic brain injury outcome variables. Outcome of traumatic brain injury was assessed by Glasgow outcome scale . ^{47, 48, 51}

To maintain the quality of data, pretest was done on 5% of samples at University of Gondar Comprehensive Specialized Hospital. The pre-test of data extraction tools Cronbach alpha result was 0.75. After the pretest was done ambiguous words and concepts were corrected accordingly. Training was given to data collectors and supervisors regarding to the data collection methods, checklist content, instruction, and includes practical demonstration. During data collection close supervision, and fast feedback was given by both principal investigator and supervisors. Necessary adjustments were done consistently on daily based and before starting data entry the collected data were checked for Inconsistencies, coding errors, completeness, correctness, clarity, missing values thoroughly and data entry was done.

After the data was collected from patient charts by using a data extraction tools and data quality assurance was assured the data were cleaned, coded and enter to Epi-info version 7 then transfer data to SPSS version of 25, for descriptive and analytic Statistical analysis. Then after the data cleaning, coding and recoding was done and cross-tabulation to assess the distribution of unfavorable and favorable outcomes of TBI in pediatrics and the data was processed by carrying out simple descriptive statistics. For categorical variable frequency with percentage distribution were employed. Box plot graphs were used to check outliers for continuous data, and the variance inflation factor (VIF) was used to determine whether there were any multi-collinear. Association of TBI related variables and demographic characteristics with the outcome of TBI in pediatrics patient at discharge were analyzed by Chi square and Binary logistic regression analysis. model goodness-of-fit was checked by using the Hosmer-Lemeshow tests (P= 0.514). Those variables with a p-value < 0.25 in bi-variable analysis were entered into multi-variable analysis with back ward stepwise method. Then, in multivariable analysis, variables of P-value ≤ 0.05 were declared as significantly associated factors with the outcome of traumatic brain injury in pediatrics. The odds ratio was used to determine the strength of association between dependent and independent variables.

The study was approved by the University of Gondar, College of Medicine and Health Sciences, School of Nursing Ethical and Research Review Committee on behalf of the Institutional Review Board (IRB) with an ethical clearance number S/N/237/2014 was given to the principal investigator to preceding the study implementation. since the study was done by retrospectively chart review without contacting patients the official letters were sent for each respective comprehensive specialized hospitals of Amhara national regional state in which the study was conducted. After supportive letter was obtained from each respective Hospital Medical Director’s office data was retrieved from the patient’s chart and records. Confidentially of all information were kept and no individual identifiers were collected.

The Mean age of study participant was 9.2 ± 5.4 years and the majority of victims were age range of 5-12 years, 150(37.1%). Male accounts higher proportion of TBI, 264(65.3%) with male to female ratio of 2:1. More than half of TBI cases were come from rural 251(62.1%). The majority of traumatic brain injury case children comes from the scene 173(42.8%) and the commonest way of transportation was ambulance 173 (42.8%). (See Table 1).

In this study, fall down accident was the commonest mechanism of traumatic brain injury in children 190(47%), followed by road traffic accident 97(24%). (See Figure 2)

Figure 2. mechanism of injury among pediatrics TBI who visited in Amhara regional state CSHs from January 1,2019 to December 30,2021 GC.

At the time of admission, 160 (39.5 %) of the total study participants had additional injuries. The most common additional injuries in children with traumatic brain injury were chest/abdominal injuries 59(36.8%) followed by soft tissue injuries 55(34.38%), maxillofacial injuries 31(19.38%) and vertebral bone fractures 15(9.38%). (See Figure 3)

Figure 3. Additional injury among pediatrics TBI patients treated in Amhara National Regional State CSHs from January 1,2019 to December 30,2021.

From the total study subjects 221(54.7%),147(36.4%) and 36(8.9%) mild, moderate and sever traumatic brain injury respectively. concerning vital sign on admission Body temperature half of the study subjects had normal body temperature 204(50.5%) and more than one-fourth of study subjects had hypoxia on addition ,112(27.7%), nearly half of case 185(45.8%) had history of Loss of consciousness and 40(9.9%) study participant had Convulsion at presentation. (See Table 2).

In this study, out of 404 patients, 133 (32.9%) had pre-hospital care. Of those patients 89(66.9%) received basic first aid after injury were happening, followed by Medication like tetanus anti -toxoid, antipain 31(23.3%). (See Table 3)

The median duration of Prehospital length of stay were 5 hours (IQ, R 2-14). most of case, 156(38.6%) seek health care service within 5-24 hours,116(28.7%) of case seek health care within 2-4 hours, 94(23.3%) case seek health care with in ≤ 1 hours and 38(9.4%) of case were come to hospital for health care service with ≥ 24 hours. The median in hospital length of stay were 3 days (IQ, R 1-7). majority of the traumatic brain injury pediatrics patients in-hospital length stay were from 2 – 7 days 245(60.6%), ≤ 1 days 121(30%) and 38(9.4%) of case stay more than 7 days. (See Table 4).

The overall prevalence of unfavorable outcomes of traumatic brain injury among pediatrics patient treated in Amahera National Regional State Compressive Specialized Hospitals were found that 12.13% (95% CI: 9.1% - 15.7 %) as indicated in figure five. Based on the Glasgow Outcome Score, nearly three-four of pediatric patients with traumatic brain injuries had good recovery at the time of discharge 292 (72.3%), followed by moderate disability 63 (19.6%), severe disability 19 (4.7%), persistent vegetative state 6 (1.5%), and death 24(5.9 %) of cases (Figure 4).

Figure 4. Outcome of TBI among pediatrics patients treated in Compressive Specialized Hospitals of Amhara National Regional State from January 1,2019 to December 30,2021G.C.

In binary logistic regression analysis, the sex of respondent, Residency, severity of traumatic brain injury, Blood glucose Level, Body temperatures, O2 saturation, Sign of increased ICP, medical Comorbidity and Prehospital length of stay were significantly associated with unfavorable outcome of traumatic brain injury. However, in multivariable logistic regression analysis only Severity TBI, blood glucose level, Sign of increased ICP and medical Comorbidity were significantly associated with outcome of traumatic brain injury patient.

This study shows having sever TBI (GCS 3-8) [AOR: 5.11(CI :1.8-14.48) and moderate TBI (GCS9-12) (AOR:2.44(CI:1.07-5.58) were significantly associated with unfavorable outcome. The severity of traumatic brain injury among sever traumatic brain injury were 5.11 times and among moderate TBI 2.44 times higher odds of developing unfavorable outcome as compared to those who had mild traumatic brain injury.

Being Hyperglycemic was 5.84 times more likely to develop unfavorable outcome of TBI than those blood glucoses levels were with in normal range (AOR: 3.01 (CI:1.1-8.04). And The odds of unfavorable outcome among those who had sign of increased ICP were 7.4 times higher than those had no sign of increased ICP (AOR:7.4(CI:3.5-15.26).

The finding of these study shows that the odds of having unfavorable outcome from traumatic brain injury were 2.65 times higher in those having medical comorbidity at presentation than those not having medical comorbidity (AOR: 2.65(CI:1.19-5.91). (See Table 5)

AOR - Adjusted Odds Ratio

CI - Confidence Interval

COD - Crud Odds Ratio

CSH - Comprehensive Specialized Hospital

CSF - Cerebrospinal Fluid

DAI -Diffuse Axonal Injury

GCS - Glasgow Coma Scale

GOS -Glasgow Outcome Scale

ICH -Intracranial hemorrhage

ICP - Intracranial pressure

ICU - Intensive Care Unit

RTA - Road Traffic Accident

TBI -Traumatic brain injury

WHO - World Health Organization

To reassure confidentiality, the data on the chart was collected without the names of the patients, and the information which is collected from this research project were keep confidential. In addition, it was not be revealed to anyone except the investigator.

Not applicable

The datasets used and/or analyzed during the current study is available upon request from the corresponding author and Co- authors.

There is no source of funding for this research. All costs were covered by the authors.

Aytenew Getabalew conceived, designed the study, analyzed the data and prepared the manuscript. Abebaw Alemayehu, Kennean Mekonnen, Bikis Liyew and Belete Melesegn assisted with the design conception, advising and reviewing the manuscript.