Síncope en Urgencias: Aproximación Clínica / Syncope in Emergency Room: Clinical Approach

Resumen El síncope es un síntoma definido como una perdida transitoria de la conciencia de inicio rápido, de corta duración y con recuperación completa y espontánea. Los picos de presentación son en la adolescencia y posterior a la 8va década de la vida. La incidencia de sincope representa del 1% al 3% de los ingresos hospitalarios y se asocia con comorbilidad cardiovascular y farmacoterapia cardiovascular siendo en los adultos mayores una causa importante de morbimortalidad. La incidencia acumulada de síncope en las mujeres es casi el doble que en los hombres. Su aparición está explicada por una disminución en el flujo sanguíneo cerebral producto del descenso del gasto cardiaco ya sea por una caída en la presión arterial sistólica por debajo de 60 mmHg o disminución en la resistencia periférica. El síncope de divide en 3 grupos: 1) Síncope reflejo, en el cual se produce un cambio repentino en la actividad del sistema nervioso autónomo que lleva a la caída en la presión arterial; 2) Síncope secundario a hipotensión ortostática, en donde la actividad simpática eferente no proporciona una suficiente vasoconstricción y 3) Síncope de causa cardiopulmonar, caracterizado por una disminución brusca y repentina del gasto cardiaco producto de arritmias o enfermedades cardiacas estructurales. Dependiendo de la causa del síncope se puede o no presentar pródromo, que más comúnmente se compone de diaforesis, calor y rubor. La verdadera pérdida de la conciencia por lo general dura menos de un minuto, aunque algunos pacientes pueden tardar varios minutos en recuperar plenamente la conciencia. Por ello el diagnóstico está basado en una buena historia clínica con un examen físico completo. El tratamiento depende de la causa y el mecanismo de los episodios sincopales. Adicionalmente se deben tener como objetivos el aliviar los síntomas y mejorar el pronóstico, lo cual implica evitar o reducir las recurrencias.

Abstract Syncope is a symptom defined as a transient loss of consciousness, of rapid onset, of short duration and with complete and spontaneous recovery. Peaks of presentation are in adolescence and after the 8th decade of life. The incidence of syncope represents 1% to 3% of hospital admissions and is associated with cardiovascular comorbidity and cardiovascular pharmacotherapy, being an important cause of morbidity and mortality in the elderly. The accumulative incidence of syncope in women is almost double than in men. Its onset is explained by a decrease in cerebral blood flow due to the decrease in cardiac output, whether due to a drop in systolic blood pressure below 60 mmHg or a decrease in peripheral resistance. The syncope is divides into 3 groups: 1) Reflex syncope, in which there is a sudden change in the autonomic nervous system activity that leads to a drop in blood pressure; 2) Syncope secondary to orthostatic hypotension, where sympathetic efferent activity does not provide sufficient vasoconstriction; and 3) Syncope of cardiopulmonary cause, characterized by an abrupt and sudden decrease in cardiac output due to arrhythmias or structural heart diseases. Depending on the cause of syncope it may or may not present prodrome, which is more commonly composed of diaphoresis, heat and flushing. True loss of consciousness usually lasts less than a minute, although some patients may take several minutes to fully regain consciousness. Therefore, the diagnosis is based on a good medical history with a complete physical examination. Treatment depends on the cause and mechanism of syncopal episodes. In addition, the goals should be to alleviate symptoms and improve prognosis, which means avoiding or reducing recurrences.

Craniectomía descompresiva para trauma craneoencefálico severo / Decompressive craniectomy for severe head trauma

La hipertensión intracraneal es la principal causa de mortalidad en los pacientes con lesiones craneales. En la actualidad la lesión traumática cerebral es un problema de salud pública en todo el mundo. La craniectomía descompresiva surge como una estrategia de tratamiento para los pacientes con hipertensión intracraneal refractaria a manejo médico. Este procedimiento requiere una técnica quirúrgica cuidadosa y exquisita, presentamos una revisión actualizada del procedimiento dirigida a los residentes en formación y a los neurocirujanos latinoamericanos.

Intracranial hypertension is the leading cause of mortality in patients with head injuries. Currently, traumatic brain injury is a public health problem worldwide. Decompressive craniectomy emerges as a treatment strategy for patients with intracranial hypertension refractory to medical management. This procedure requires careful surgical technique and exquisite, we present a review of the procedure intended for residents in training and Colombian neurosurgeon.

[Neuro-critical management of glycemia in spontaneous intracerebral hemorrhage: review of the literature]. / Manejo neurocrítico de la glicemia en la hemorragia intracerebral espontánea: revisión de la literatura.

Spontaneous cerebral hemorrhage or intracranial hemorrhage represents between 10 and 15% of all cerebrovascular events. Intracerebral hemorrhage is far less frequent than ischemic stroke, but leads to increased morbidity and mortality, one of the leading causes of severe disability. Several changes have been identified in the field of intracerebral hemorrhage, including endocrine. These stress-mediated mechanisms exacerbate secondary injury. Deep knowledge of the injuries that are directly involved in the alterations of glucose in the context of an intracerebral hemorrhage, offers a vision of how the cytotoxicity, neuronal death and metabolic disturbances alter the prognosis of patients with spontaneous intracerebral hemorrhage.

Effects of Glycemic Level on Outcome of Patients with Traumatic Brain Injury: A Retrospective Cohort Study.

OBJECTIVE: To determine the effects of glycemic level on outcome patients with traumatic brain injury. METHODS:  From September 2010 to December 2012, all medical records of adult patients with TBI admitted to the Emergency Room of Laura Daniela Clinic in Valledupar City, Colombia, South America were enrolled. Both genders between 18 and 85 years who referred during the first 48 hours after trauma, and their glucose level was determined in the first 24 hours of admission were included. Adults older than 85 years, with absence of Glasgow Coma Scale (GCS) score and a brain Computerized Tomography (CT) scans were excluded. The cut-off value was considered 200 mg/dL to define hyperglycemia. Final GCS, hospital admission duration and complications were compared between normoglycemic and hyperglycemic patients. RESULTS: Totally 217 patients were identified with TBI. Considering exclusion criteria, 89 patients remained for analysis. The mean age was 43.0±19.6 years, the mean time of remission was 5.9±9.4 hours, the mean GCS on admission was 10.5±3.6 and the mean blood glucose level in the first 24 hours was 138.1±59.4 mg/dL. Hyperglycemia was present in 13.5% of patients. The most common lesions presented by patients with TBI were fractures (22.5%), hematoma (18.3%), cerebral edema (18.3%) and cerebral contusion (16.2%). Most of patients without a high glucose level at admission were managed only medically, whereas surgical treatment was more frequent in patients with hyperglycemia (p=0.042). Hyperglycemia was associated with higher complication (p=0.019) and mortality rate (p=0.039). GCS was negatively associated with on admission glucose level (r=0.11; p=0.46). CONCLUSION: Hyperglycemia in the first 24-hours of TBI is associated with higher rate of surgical intervention, higher complication and mortality rates. So hyperglycemia handling is critical to the outcome of patients with traumatic brain injury.

Craniectomia descompresiva para trauma craneoencefálico severo: aspectos importantes / Decompressive craniectomy for severe cranioencephalic trauma: important issues

La hipertensión intracraneal es la principal causa de mortalidad en los pacientes con lesiones craneales. En la actualidad la lesión traumática cerebral es un problema de salud pública en todo el mundo. La craniectomía descompresiva surge como una estrategia de tratamiento para los pacientes con hipertensión intracraneal refractaria a manejo médico. Este procedimiento requiere una técnica quirúrgica cuidadosa y exquisita, presentamos una revisión actualizada del procedimiento dirigida a los residentes en formación y a los neurocirujanos latinoamericanos.

Intracranial hypertension is the leading cause of mortality in patients with head injuries. Currently, traumatic brain injury is a public health problem worldwide. Decompressive craniectomy emerges as a treatment strategy for patients with intracranial hypertension refractory to medical management. This procedure requires careful surgical technique and exquisite, we present a review of the procedure intended for residents in training and Colombian neurosurgeon