Traumatismo craneoencefálico pediátrico grave (II): factores relacionados con la morbilidad y mortalidad

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

OBJECTIVE

To identify early prognostic factors that lead to an increased risk of unfavorable prognosis.

DESIGN

Observational cohort study from October 2002 to October 2017.

SETTING AND PATIENTS

Patients with severe TBI admitted to intensive care were included.

VARIABLES AND INTERVENTIONS

Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis.

RESULTS

98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients.

CONCLUSIONS

it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

OBJECTIVE

To identify early prognostic factors that lead to an increased risk of unfavorable prognosis.

DESIGN

Observational cohort study from October 2002 to October 2017.

SETTING AND PATIENTS

Patients with severe TBI admitted to intensive care were included.

VARIABLES AND INTERVENTIONS

Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS ≤3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis.

RESULTS

A total of 98 patients were included, 61.2% males, median age 6.4years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients.

CONCLUSIONS

It is possible to identify prognostic factors of poor evolution in the first 24hours after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

[Monitoring intracranial pressure in severe traumatic brain injury]

INTRODUCTION

Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries.

OBJECTIVE

To describe the clinical experience of pediatric patients with severe TBI.

PATIENTS AND METHOD

A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up.

RESULTS

Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter.

CONCLUSION

Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.

[Prognostic factors in severe traumatic brain injury]

OBJECTIVE

To describe the factors associated to mortality of patients with severe traumatic brain injury (TBI).

DESIGN

A retrospective observational study was made of patients with severe TBI covering the period between 1 January 2007 and 31 December 2010.

SETTING

Virgen de la Vega Hospital, Salamanca (Spain).

PATIENTS

All patients hospitalized during the consecutive study period.

MAIN VARIABLES OF INTEREST

The dependent variable has been the death rate, while the independent variables were divided into two groups: epidemiological and clinical.

RESULTS

The mean patient age was the 50.84 years; 75.5% were males. The average score on the Glasgow Coma Scale (GCS) was 5.09, and the average Injury Severity Score (ISS) was 30.8. Higher mortality was observed in older patients with a higher ISS score. A total of 68.1% of the patients in which intracranial pressure (ICP) was monitored showed intracranial hypertension (ICH). The mortality rate in patients with severe TBI was 36.8%, and was associated mainly to a lower GCS score, the existence of hyperglycemia, coagulopathy, hypoxemia, the presence of mydriasis and shock. The independent mortality indicators in patients with severe TBI were the existence of mydriasis (OR: 32.75), the GCS score (OR: 2.65) and hyperglycemia (OR: 6.08).

CONCLUSIONS

The existence of mydriasis, the GCS score and hyperglycemia should be taken into account as prognostic factors in TBI patients.