Sérgio Diniz Guerra

Distúrbio de coagulação em crianças e adolescentes com traumatismo cranioencefálico moderado e grave

OBJECTIVES: To describe the epidemiological profile of children and adolescents with moderate to severe traumatic brain injury admitted to an intensive care unit; to describe the frequency of coagulation disorders in these patients; to determine the relationship between coagulopathy and trauma severity; to assess the factors associated with coagulopathy; and to assess the effect of coagulopathy on the mortality of these patients. METHODS: Cross-sectional study with 301 patients aged up to 16 years admitted to an intensive care unit due to moderate to severe traumatic brain injury, carried out over a 5-year period. The coagulation profile was associated with clinical, epidemiological and CT findings. Univariate and multivariate analyses were used to check the association between coagulopathy and mortality. RESULTS: Minimum age was 23 days, and maximum age was 16 years (mean of 7.9 years). About 77% of patients had coagulopathy, whose occurrence was directly associated with the severity of the trauma, but not with the rise in mortality. The factors associated with the presence of coagulopathy were the following: severity of the traumatic brain injury (OR = 2.83; 95%CI 1.58-5.07), diagnosis of brain swelling on cranial computed tomography (OR = 2.11; 95%CI 1.13-4.07) and occurrence of chest and/or abdominal injury (OR = 2.07; 95%CI 1.11-4.00). Approximately 35% of patients died. The multivariate analysis showed that the factors associated with an increased risk of death were presence of sodium disorders (OR = 5.56; 95%CI 2.90-10.65), hypotension in the intensive care unit (OR = 12.58; 95%CI 4.40-35.00) and acute respiratory distress syndrome (OR = 13.57; 95%CI 1.51-121.66). CONCLUSION:The development of coagulopathy is a frequent complication in patients with moderate to severe traumatic brain injury. Even though it is not closely associated with death in this study, it may be regarded as a marker of injury severity.

Coagulation disorder in children and adolescents with moderate to severe traumatic brain injury

OBJECTIVES To describe the epidemiological profile of children and adolescents with moderate to severe traumatic brain injury admitted to an intensive care unit; to describe the frequency of coagulation disorders in these patients; to determine the relationship between coagulopathy and trauma severity; to assess the factors associated with coagulopathy; and to assess the effect of coagulopathy on the mortality of these patients. METHODS Cross-sectional study with 301 patients aged up to 16 years admitted to an intensive care unit due to moderate to severe traumatic brain injury, carried out over a 5-year period. The coagulation profile was associated with clinical, epidemiological and CT findings. Univariate and multivariate analyses were used to check the association between coagulopathy and mortality. RESULTS Minimum age was 23 days, and maximum age was 16 years (mean of 7.9 years). About 77% of patients had coagulopathy, whose occurrence was directly associated with the severity of the trauma, but not with the rise in mortality. The factors associated with the presence of coagulopathy were the following: severity of the traumatic brain injury (OR=2.83; 95%CI 1.58-5.07), diagnosis of brain swelling on cranial computed tomography (OR=2.11; 95%CI 1.13-4.07) and occurrence of chest and/or abdominal injury (OR=2.07; 95%CI 1.11-4.00). Approximately 35% of patients died. The multivariate analysis showed that the factors associated with an increased risk of death were presence of sodium disorders (OR=5.56; 95%CI 2.90-10.65), hypotension in the intensive care unit (OR=12.58; 95%CI 4.40-35.00) and acute respiratory distress syndrome (OR=13.57; 95%CI 1.51-121.66). CONCLUSION The development of coagulopathy is a frequent complication in patients with moderate to severe traumatic brain injury. Even though it is not closely associated with death in this study, it may be regarded as a marker of injury severity.

Traumatismo cranioencefálico grave em crianças e adolescentes

JUSTIFICATIVA E OBJETIVOS: Apresentar uma revisao critica do traumatismo cranioencefalico (TCE) em criancas e adolescentes, enfocando o trauma grave, as taxas e os aspectos relacionados com a mortalidade e as principais medidas terapeuticas. CONTEUDO: Revisao sistematica dos artigos incluidos no MEDLINE, SciELO e Lilacs, no periodo compreendido entre 1985 e 2006, utilizando as seguintes palavras-chave: traumatic brain injury, craniocerebral trauma, children e mortality, alem dos principais livros-texto sobre o assunto. Foram analisados tambem os Guidelines of Brain Trauma Foundation de 2000 e 2003, sendo selecionados os principais trabalhos citados. O traumatismo cranioencefalico e uma das principais causas de morte e sequelas em criancas e adolescentes. As taxas de mortalidade variaram entre 10% e 55%, principalmente em razao dos criterios de selecao utilizados, da gravidade dos pacientes e dos locais onde foram realizados os estudos. Em geral, a mortalidade em criancas foi menor que as descritas em pacientes adultos. Os principais fatores relacionados com a mortalidade em criancas foram a pontuacao na escala de coma de Glasgow, a hipotensao arterial, o edema e ingurgitamento cerebral difusos e a baixa pressao de perfusao encefalica. O tratamento do TCE grave visa a correcao dos fatores relacionados com a lesao cerebral secundaria. CONCLUSOES: Os fatores relacionados com melhor prognostico em criancas ainda permanecem inconclusivos, havendo algumas divergencias entre os estudos. Grande parte destes fatores e corrigivel ou evitavel, com reanimacao hidrica inicial agressiva, tratamento cirurgico em tempo habil, monitorizacao e cuidados intensivos adequados.BACKGROUND AND OBJECTIVES Present a critical review of traumatic brain injury (TBI) in children and adolescents, focusing on severe TBI, the mortality and the factors related with poor outcome. CONTENTS It was made a systematic review in MEDLINE, SciElo e Lilacs, with the key words: traumatic brain injury, craniocerebral trauma, children and mortality. The most important articles related in the Guidelines of Brain Trauma Foundation (2000 e 2003) were selected too. TBI is one of the most important causes of mortality and morbidity in children and adolescents, and morbidity in children and adolescents. The mortality variation was between 10% and 55%, depending of the patients select criteria, trauma severity and units where the studies were made. The children mortality was, in general, lower than that found in adults and the most important factors related with an increased mortality were: Glasgow Coma Score, hypotension, cerebral swelling and lower cerebral perfusion press. Severe TBI endpoint treatment is to correct the secondary brain lesions related factors. CONCLUSIONS The factors related with better outcomes in children with severe TBI are still obscures, despite the large number of studies, large numbers of studies. Many of these factors can be avoided or correct by aggressive fluid resuscitation, surgery treatment, monitoration and adequate intensive care.

Factors associated with intracranial hypertension in children and teenagers who suffered severe head injuries

OBJECTIVE To analyze factors associated with intracranial hypertension in pediatric patients who suffered severe head injuries. METHODS Retrospective cohort study, with data collected from September 1998 through August 2003, including patients aged 0 to 16 who suffered severe head injuries, Glasgow score < 9, and submitted to intracranial pressure (ICP) monitoring (n = 132). Intracranial hypertension (IH) was defined as an episode of ICP > 20 mmHg requiring treatment, while refractory IH was ICP over 25 mmHg requiring barbiturates or decompressive craniectomy. Univariate analysis was followed by multivariate analysis; variables were considered significant if p < 0.05. RESULTS Ages ranged from 2 months to 16 years, median age 9.7 (6.0-2.3) years. Glasgow scores ranged from 3 to 8, median 6 (4-7). Traffic accidents were responsible for 79.5% of events. Monitoring devices were installed, on average, 14 hours after trauma, median time 24 hours. One hundred and three patients (78%) had IH, while 57 (43.2%) had refractory IH. In multivariate analysis, younger age ranges were associated with IH [relative risk = 1.67 (1.03-2.72); p = 0.037], and abnormal postures were associated with refractory IH [relative risk = 2.25 (1.06-4.78)]. The group mortality rate was 51.5%; it was correlated with use of barbiturates in refractory IH and low cerebral perfusion pressure at the intensive care unit. CONCLUSIONS IH and refractory IH were frequent events in pediatric patients who suffered severe head injuries. The younger the patient, the greater the chance of developing IH. The presence of abnormal postures was found to be a risk factor for refractory IH.

Pediatric head injury

OBJECTIVE: To present an update on head injury with a review of the literature. The authors emphasize the importance of the secondary brain injury prevention and describe the basic principles of the treatment, from the site of the accident to the intensive care unit.METHODS: Papers and abstracts from the database Lilac in the period between 1984 and 1999 and Medline between 1995 and 1999 were reviewed as well as textbooks and the Guidelines of the American Brain Trauma Foundation 1995.CONCLUSIONS: Despite the vast literature on the subject there have been many controversies regarding the therapeutic proposals. Prospective studies will be required in order to verify their efficacy. Nevertheless, the prevention and treatment of the secondary brain injury has been shown to be effective in reducing the disability and mortality of the patient with head trauma.

Uso do sulfato de magnésio venoso para tratamento da asma aguda grave da criança no pronto-socorro

Severe acute asthma is a medical emergency that must be quickly diagnosed and treated. Initial treatment includes a bronchodilator agent and systemic corticosteroids. In severe cases with poor response to the standard treatment, intravenous magnesium sulfate is a therapeutic option. This article aimed a literature review on the use of intravenous magnesium sulfate in the emergency room treatment of children with acute asthma. The treatment parameters of effectiveness, indication, dosage, adverse effects and contraindications were assessed. A narrative review of the literature based on a search of the Medline and Lilacs databases and the Cochrane Database of Systematic Reviews for articles published between 2000 and 2010 was conducted. The keywords used included the following: asthma, children, emergency and magnesium sulfate. Eight controlled clinical trials, three meta-analyses, one retrospective study, eight review articles and one cross-sectional study were included. A total of 21 articles were analyzed. Several authors reported that intravenous magnesium was effective in the treatment of acute asthma in children. Adverse effects were rare. The use of intravenous magnesium sulfate was indicated for patients with moderate to severe acute asthma not responding to initial treatment with a bronchodilator agent and systemic corticosteroids. Few contraindications were reported but included kidney failure and atrioventricular block. Reports of adverse drug interactions with magnesium were rare. Although reported as safe, intravenous magnesium is infrequently used in children with acute asthma. Most often it is used in severe, progressed cases to prevent respiratory failure and/or admission to the intensive care unit. Intravenous magnesium was concluded to be effective and safe in children with severe acute asthma, although its use in the emergency room is still limited.