Relationship between prehospital clinical status intracranial pressure and outcomes in pediatric patients with severe head trauma

Introduction: The prehospital phase of the management of pediatric severe traumatic brain injury may have a direct influence on the results. Objective: To evaluate the influence of prehospital variables on intracranial pressure and the results in pediatric patients with severe TBI. Method: A descriptive study of 41 pediatric patients who were admitted to the medical emergency department and later admitted to the pediatric intensive care unit due to severe head trauma was carried out between January 2003 and December 2018. Results: children aged 5-17 years predominate, and the highest number of cases were received between 0-3h at the neurotrauma center. Of the 41 cases, 27 arrived with a non-expedited airway and hypoxia was verified upon arrival by pulse oximetry. A correlation was observed between arterial hypotension on admission and elevated intracranial pressure in 9 of 15 children (60%) and in the deceased (40%). Discussion: Clinical conditions, oxygenation, arterial hypotension, and treatment in the prehospital phase may influence the state of intracranial pressure and other intracranial variables in pediatric patients with severe head injury.

Introducción: La fase prehospitalaria del manejo del traumatismo craneoencefálico grave pediátrico puede tener una influencia directa en los resultados. Objetivo: Evaluar la influencia de variables prehospitalarias sobre la presión intracraneal y los resultados en pacientes pediátricos con TCE grave. Metodología: Se realizó un estudio descriptivo de 41 pacientes pediátricos que ingresaron al servicio de urgencias médicas y posteriormente ingresaron a la unidad de cuidados intensivos pediátricos por traumatismo craneoencefálico severo entre enero de 2003 y diciembre de 2018. Resultados: predominan los niños de 5 a 17 años, y el mayor número de casos se recibieron entre las 0-3h en el centro de neurotrauma. De los 41 casos, 27 llegaron con vía aérea no acelerada y se verificó hipoxia al llegar mediante oximetría de pulso. Se observó correlación entre hipotensión arterial al ingreso y presión intracraneal elevada en 9 de 15 niños (60%) y en los fallecidos (40%). Discusión: Las condiciones clínicas, la oxigenación, la hipotensión arterial y el tratamiento en la fase prehospitalaria pueden influir en el estado de la presión intracraneal y otras variables intracraneales en pacientes pediátricos con traumatismo craneoencefálico grave.

Contribución de los hallazgos tomográficos al diagnóstico de la hipertensión intracraneal en el traumatismo craneoencefálico grave

Introducción: El traumatismo craneoencefálico es responsable de más de 500 000 visitas a departamentos de urgencias, 95 000 hospitalizaciones y 7 000 muertes en la población infantil. La monitorización clínica se apoya en técnicas imagenológicas, entre otras. Objetivo: Relacionar los hallazgos tomográficos encontrados, a través de la clasificación de Marshall al ingreso y diámetro de la vaina del nervio óptico y su asociación con la presión intracraneal y con los resultados en el paciente pediátrico con traumatismo craneoencefálico grave. Métodos: Estudio descriptivo prospectivo con todos los pacientes pediátricos aquejados de traumatismo craneoencefálico grave entre enero de 2003 y diciembre de 2017. Resultados: De los 41 casos, se encontró relación entre los niveles de presión intracraneal y el grado de luxación de la línea media >10 mm en 10 enfermos (62,5 %) y con el diámetro de la vaina del nervio óptico (>5,5 mm) por tomografía de cráneo en 12 (75,0 %), igualmente existió relación entre esas dos variables con los resultados a los 6 meses de evolución. Conclusiones: La utilización de la tomografía de cráneo simple como herramienta para la determinación de variables utilizadas en el monitoreo no invasivo de la presión intracraneal como son la clasificación tomográfica de Marshall, la luxación de la línea media y la medición del diámetro de la vaina del nervio óptico, permite identificar incrementos de la presión intracraneal. Esto pudiera utilizarse para el tratamiento intensivo de los pacientes pediátricos con traumatismo cráneo encefálico grave, sin necesidad de la utilización de monitoreo invasivo en ellos.

Introduction: Traumatic brain injury is responsible for more than 500,000 visits to the emergency services, 95,000 hospitalizations and 7,000 deaths in children. Clinical monitoring is based on imaging techniques, among others. Objective: To relate the tomographic findings found, through Marshall's classification at the entrance and diameter of the optic nerve sheath and its association with intracranial pressure and with the results in the pediatric patient with severe head trauma. Methods: Prospective descriptive study with all pediatric patients suffering from severe head trauma between January 2003 and December 2017. Results: Of the 41 cases, a relationship was found between the levels of intracranial pressure and the degree of dislocation of the midline >10 mm in 10 patients (62.5%) and with the diameter of the optic nerve sheath (>5.5 mm) by skull tomography in 12 (75.0%); there was also a relationship between these two variables with the results at 6 months of evolution. Conclusions: The use of simple tomography of the skull as a tool for the determination of variables used in the non-invasive monitoring of intracranial pressure such as Marshall tomographic classification, midline dislocation and measurement of the diameter of the optic nerve sheath, allows to identify increases in intracranial pressure. This could be used for the intensive treatment of pediatric patients with severe head trauma, without the need for invasive monitoring in them.

Presión positiva al final de la espiración, presión intracraneal y presión de perfusión cerebral en el paciente pediátrico crítico con traumatismo craneoencefálico grave / Positive end expiration pressure, intracranial pressure and cerebral perfusion pressure in the severe traumatic brain injury in child / Pressão positiva ao final da expiração, pressão intracraniana e pressão de perfusão cerebral em pacientes pediátricos criticamente enfermos com traumatismo cranioencefálico grave

Resumen: Introducción: el uso de presión positiva al final de la espiración mejora la oxigenación y recluta alvéolos, aunque también provoca alteraciones hemodinámicas e incrementa la presión intracraneal. Material y métodos: se realizó un estudio preexperimental de un solo grupo en pacientes pediátricos aquejados de traumatismo craneoencefálico grave, con hipoxemia asociada, tratados con diferentes niveles de presión positiva al final de la espiración, a los que se les monitorizó la presión intracraneal y la presión de perfusión cerebral para evaluar el efecto de esta maniobra ventilatoria en las variables intracraneales. Resultados: predominaron las edades entre cinco y 17 años, 14 (73.68%) y la escala de coma de Glasgow al ingreso de ocho a nueve puntos (47.36%). La presión intracraneal aumenta cuando la presión positiva al final de la espiración supera los 12 cmH2O. La escala de coma de Glasgow al ingreso de ocho puntos se asoció con secuelas ligeras o ausencia de secuelas (47.36%), todos los niños con tres puntos fallecieron. Conclusiones: el empleo de presión positiva al final de la espiración en el traumatismo craneoencefálico grave requiere de monitorización continua de la presión intracraneal. Corregir la hipertensión intracraneal y la inestabilidad hemodinámica son condiciones necesarias previas al tratamiento.

Abstract: Introduction: the use of positive end expiratory pressure improves oxygenation and recruits pulmonary alveoli, however at the same time it leads to hemodynamic changes and increase intracranial pressure. Material and methods: a prospective descriptive study was done with pediatric patients afflicted with severe traumatic brain injury associated with hypoxemia and treated with different levels of positive end expiratory pressure, to whom the intracranial pressure and cerebral perfusion pressure were monitored so as to evaluate the effect of this ventilation maneuver over the intracranial variables. Results: patients with age between 5-17 years old as well as male sex, 14 (73.68%) were predominant. 9 (47.36%) showed Glasgow coma scale of 8 points on admission. Intracranial pressure starts to rise when the positive end expiratory pressure exceeds 12 cmH2O. Glasgow coma scale with 8 points was associated with mild disability or no disability (47.36%). All the patients that scored 3 points died. Conclusions: the use of positive end expiratory pressure to correct hypoxemia was an applicable therapeutic alternative as long as continuous intracranial pressure monitoring was available in a systematic and personalized way. The correction of intracranial hypertension and hemodynamic instability were a necessary condition before using the ventilatory maneuver in these patients.

Resumo: Introdução: o uso de pressão positiva no final da expiração melhora a oxigenação e recruta alvéolos, embora também cause alterações hemodinâmicas e aumente a pressão intracraniana. Material e métodos: realizou-se um estudo pré-experimental de um único grupo em pacientes pediátricos vítimas de traumatismo cranioencefálico grave, com hipoxemia associada, tratados com diferentes níveis de pressão positiva ao final da expiração, nos quais foram monitoradas a pressão intracraniana e a pressão de perfusão cerebral, para avaliar o efeito desta manobra ventilatória em variáveis intracranianas. Resultados: predominou a faixa etária entre 5-17 anos, 14 (73.68%) e a escala de coma de Glasgow na admissão de 8 pontos, 9 (47.36%). A pressão intracraniana aumenta quando a pressão positiva no final da expiração excede 12 cmH2O. A escala de coma de Glasgow na admissão de 8 pontos foi associada a sequelas leves ou sem sequelas (47.36%), todas as crianças com 3 pontos morreram. Conclusões: a utilização de pressão positiva no final da expiração no TCE grave requer monitorização contínua da pressão intracraniana. A correção da hipertensão intracraniana e da instabilidade hemodinâmica são condições necessárias prévias ao tratamento.

Intervenciones de enfermería en la atención del adulto con traumatismo craneoencefálico grave / Nursing Intervention in the Attention of Adult with Traumatic Severe brain Injury

El traumatismo craneoencefálico es el daño cerebral causado por una fuerza externa, que puede producir una alteración del estado de conciencia, resultando un deterioro del funcionamiento de las capacidades cognitivas y físicas. La Escala de Coma de Glasgow nos permite clasificar el grado de un Traumatismo Craneoencefálico, cuyo tratamiento debe iniciarse con una adecuada reanimación, según el protocolo del soporte vital avanzado al trauma. Métodos: Se estableció una secuencia estandarizada para la búsqueda de información en la base de datos electrónicas: PudMed, Scielo, Cuiden, Ciberindex, Cochrane BVS, y otras bases disponibles. La búsqueda fue limitada a 10 años a la fecha actual, en idioma inglés o español, de las cuales 10 fueron revisiones sistemáticas y 14 revisiones narrativas útiles para el desarrollo de esta guía. Resultados: El manejo inicial en todo paciente con traumatismo craneoencefálico debe estar respaldado por los principios de Soporte Vital Avanzado de Trauma (ATLS) si se genera un episodio de hipoxia aumenta su mortalidad en un 50%, en un episodio de hipotensión en un 100%. Todas las alteraciones a nivel de conciencia son emergencias letales hasta que las funciones vitales estén estabilizadas. Conclusión: La Guía de Práctica Clínica permite que el personal de enfermería estandarice y proporcione la práctica diaria en el cuidado y manejo del paciente con Traumatismo Craneoencefálico Grave y sirva de base para la toma de decisiones. Traumatismo Craneoencefálico Grave, Soporte Vital Avanzado, Escala de Glasgow, enfermería.

Introduction: Traumatic brain injury is defined as brain damage caused by an external force, and can produce an altered state of consciousness, resulting in deterioration of the functioning of cognitive and physical abilities. The Glasgow Coma Scale allows us to classify the degree of traumatic brain injury. Treatment should be initiated with appropriate resuscitation, according to the protocol advanced trauma life support. Method: PudMed, Scielo, Cuiden, Ciberindex, Cochrane VHL and other bases were used; standard sequence for finding information in electronic databases was established. The search was limited to 10 years from the current date, in English or Spanish language. 10 systematic and 14 narrative reviews were useful for the development of this guide. Results: The initial management in all patients with head trauma must be supported by the principles of Advanced Trauma Life Support (ATLS). If an episode of hypoxia is generated increase mortality by 50%; low blood pressure episode increases it by 100%. All alterations of consciousness are emergencies until vital functions are stabilized. Conclusion: Clinical Practice Guide allows nurses to standardize and give better service in the care and management of patients with severe head trauma. It serves as a basis for decision-making. Severe head trauma, Advanced Life Support, GCS, nursing.

Introdução: Lesão cerebral traumática é dano cerebral causado por uma força externa, que pode produzir um estado alterado de consciência, resultando em uma deterioração do funcionamento das habilidades cognitivas e físicas. A Escala de Coma de Glasgow nos permite classificar o grau de lesão cerebral traumática. Cujo tratamento deve ser iniciado com a reanimação adequado, de acordo com o suporte de vida trauma protocolo avançado. Métódo: PudMed, Scielo, CUIDEN, Ciberindex, Cochrane BVS e outras bases disponíveis: uma seqüência padrão para busca de informações em bases de dados electrónicas foi estabelecido. A busca foi limitada a 10 anos a partir da data atual, em Inglês ou espanhol. Dos quais 10 eram sistemática e narrativa avaliações 14 útil para o desenvolvimento deste Guia comentários. Resultados: A conduta inicial em todos os pacientes com traumatismo craniano deve ser apoiada pelos princípios do Advanced Trauma Life Support (ATLS) se um episódio de hipoxia é gerado mortalidade aumenta em 50%, um episódio hipotensivo 100%. Todas as alterações são de nível letal de emergências consciência até as funções vitais são estabilizadas. Conclusões: Guia Clinical Practice permite enfermeiros padroniza e fornece prática diária no cuidado e tratamento de pacientes com traumatismo craniano grave e servir como base para a tomada de decisões. traumatismo craniano grave, Suporte Avançado de Vida, GCS, de enfermagem.

Clinical Analysis of Posttraumatic Infarct Patients

Posttraumatic cerebral infarction is a recognized complication of craniocerebral trauma, but, its frequency, cause, and influence on mortality are not well defined. During a two year period, 706 patients with head trauma were examined in our hospital with cranial CT studies. The CT findings which strongly suggested the herniation were seen in 46 patients. The posttraumatic cerebral infarction was diagnosed retrospectively in 18 of these patients. Detailed information, including CT findings were recorded from 1 to 10 days after admission. Posttraumatic cerebral infarctions were seen in the vascular territories of the middle cerebral artery(PCA) in 9 patients, posterior cerebral artery(PCA) in 4 patients, anterior cerebral artery(ACA) in 3 patients, and multiple in 2 patients. Outcomes of these 18 patients were severely disabled in 8 patients, moderate disabled in 6 patients, and death in 3 patients. Only one remaining patient was demonstrated a good recovery. These results suggest that cerebral infarction with severe head trauma might be associated with significantly bad influence on outcome of these patients when compared with those without cerebral infarction.

Magnetic Resonance Imaging in Severe Head Injury: Comparison with Computed Tomography

Magnetic resonance imaging(MRI) and computed tomography(CT) in 30 patients with severe head trauma were compared. MRI was superior to CT in detection of intracerebral and extracerebral traumatic lesions. The results obtained were as follows : 1) 27 intracerebral(18 cerebral contusions, 5 diffuse axonal injuries & 4 intracerebral hematomas) and 13 extracerebral traumatic lesions(4 acute epidural hematomas, 4 subdural hygromas, 2 subarachnoid hemorrhages, 1 acute subdural hematoma, 1 chronic subdural hematoma & 1 pneumocephalus) in 30 patients were seen on CT and/or MRI. 2) Group I lesions which seen on MRI and not seen on CT were 5 diffuse axonal injuries(100%), & 8 cerebral contusions(44%), and group II lesions which seen on CT and MRI with better visualization on MRI were 6 cerebral contusions(33%), 2 intracerebral hematomas(50%), & 3 subdural hygromas(75%). 3) Group III lesions which seen on CT and MRI equally well were 4 cerebral contusions(22%), 2 intracerebral hematomas(50%), 2 acute epidural hematomas(50%), 2 subarachnoid hemorrhages(100%), 1 chronic subdural hematoma(100%), 1 subdural hygroma(25%) & 1 pneumocephalus(100%). 4) Group IV lesions which seen on CT and MRI with better visualization on CT were 2 acute epidural hematomas(50%), & 1 acute subdural hematoma(100%), and lesion which seen on CT and not seen on MRI was not. 5) 21 intracerebral lesions of group I and II were located on temporal(11), parietal(3), frontal(2) and occipital lobes(2), basal ganglia(1), brain stem(1) and cerebellum(1). 6) We recommended MRI in the acute stage of severe head trauma for accurate diagnosis and evaluation of intracerebral traumatic lesions, especially diffuse axonal injuries and cerebral contusions, which were not visualized clearly on CT.