Caracterización clínico-quirúrgico, neuroimagenológico y por neuromonitorización del trauma craneoencefálico en la provincia matanzas. 2016-2018 / Clinical-surgical, neuroimaging and neuromonitored characterization of the encephalococranial trauma in the province of Matanzas. 2016-2018

RESUMEN Introducción: el traumatismo encefalocraneano es una causa frecuente de mortalidad y morbilidad. Según datos epidemiológicos aporta la mayor cantidad de fallecidos en menores de 45 años a nivel mundial. Objetivo: caracterizar el trauma craneoencefálico desde el punto de vista clínico-quirúrgico, neuroimagenológico y por neuromonitorización en los pacientes investigados. Materiales y métodos: estudio observacional, descriptivo, transversal, en el Servicio de Neurocirugía del Hospital Provincial Clínico Quirúrgico Docente José Ramón López Tabrane y Comandante Faustino Pérez Hernández, de Matanzas, durante el periodo comprendido entre enero del 2016 a enero del 2018. Resultados: predominó el sexo masculino con el 71,7% de los casos, la mayor prevalencia estuvo en edades inferiores a 48 años con el 80,1 %. La mayor cantidad presentaba un traumatismo encefalocraneano leve con el 56% de los casos seguido del traumatismo encefalocraneano moderado y severo con el 29% y 15% de los casos respectivamente. Predominaron las fracturas lineales (45,8%), seguido de las contusiones sin efecto de masa y los hematomas subdurales con el 24,2% y 23,3%. La mayoría de los pacientes presentó una escala de Marshall II con el 40,8%. Las cifras de presión intracraneal entre de 20-40 mmHg se presentó con mayor frecuencia (44,4 %). Conclusiones: la mitad de los pacientes neuromonitorizados presentaron una saturación del golfo de la vena yugular dentro de parámetros normales con el 50%. La operación más practicada fue la evacuación de hematomas subdurales con el 29,4%.

ABSTRACT Introduction: the encephalocranial trauma (ECT) is a frequent cause of mortality and morbidity. According to epidemiological data, it causes the highest number of deaths in people aged less than 45 years worldwide. Objective: to characterize the encephalocranial trauma from the clinical-surgical, neuroimaging and neuromonitoring point of view in the studied patients. Materials and methods: observational, descriptive, cross-sectional study carried out in the Neurosurgery Service of the Provincial Teaching Surgical Clinical Hospitals "Jose Ramon Lopez Tabrane" and "Comandante Faustino Perez Hernandez", of Matanzas, during the period from January 2016 to January 2018. Results: male sex predominated with 71.7% of the cases; the highest prevalence was in ages below 48 years with 80.1%. Most of them presented a mild encephalocranial trauma with 56% of the cases followed by moderate and severe encephalocranial trauma with 29% and 15% of the cases respectively. Linear fractures predominated (45.8%), followed by contusions without mass effect and subdural hematomas with 24.2% and 23.3%. Most of patients presented a Marshall II scale with 40.8%. The intracranial pressure between 20-40 mmHg occurred more frequently (44.4%). Conclusions: half of the neuromonitored patients presented jugular vein gulf saturation within normal parameters with 50%. The most practiced operation was the evacuation of subdural hematomas with 29.4%.

Trauma cranioencefálico / Traumatic brain injury

O traumatismo cranioencefálico é uma lesão muito comum nas emergências. É de fundamental importância o reconhecimento dos sinais de gravidade e seu adequado manejo, devido à alta taxa de morbidade e mortalidade associado a esse mecanismo de lesão.

Traumatic brain injury is common in emergencies. The recognition of the severity and the warning signs and his proper management is essential due to the high morbidity and mortality of this type of injury.

Diretrizes de atenção à reabilitação da pessoa com traumatismo cranioencefálico / Guidelines for the rehabilitation of individual with traumatic brain injury / Directrices para la atención a la rehabilitación de la persona con traumatismo cranioencefálico

elaboração das Diretrizes de Atenção à Reabilitação da Pessoacom TCE baseou-se na literatura atualizada sobre o tema. A buscafoi limitada às línguas inglesa, espanhola, francesa e portuguesa. Foirealizada por um grupo de especialistas, de reconhecimento nacionale internacional. A elaboração das diretrizes foi alcançada por meioda discussão dos resultados do levantamento bibliográfico e da trocapresencial do grupo acerca de suas experiências em relação ao TCE...

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.

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

Trauma de cráneo en pediatría: conceptos, guías, controversias y futuro / Pediatric brain trauma: concepts, guidelines, controversies and future

La siguiente es una revisión de los aspectos más importantes del conocimiento actual y las proyecciones futuras del manejo del trauma craneano en la edad pediátrica. El trauma craneano es una de las causas más importantes de muerte y discapacidad en niños, adolescentes y adultos jóvenes. Desde un punto de vista fisiopatológico se realizará una descripción de los tipos de lesión cerebral, clasificándola como primaria y secundaria. Se describirán los distintos tipos de trauma clasificados según su gravedad y se abordarán los aspectos más relevantes de su manejo. Luego se abordarán temas considerados controvertidos en el manejo del trauma grave con acento en monitorización, presión intra craneana, presión de perfusión cerebral, presión tisular de oxígeno, manitol, solución de sodio hipertónico e hipotermia. Finalmente, se comentarán desafíos futuros como la evaluación de las lesiones con resonancia magnética, el monitoreo y medición de metabolitos intra-cerebrales, el uso de doppler para la evaluación de la regulación del flujo sanguíneo cerebral, la medición de un índice de reactividad vascular y el uso de EEG continuo.

A review of the current knowledge and management as well as future projections of pediatric head trauma is presented. Head trauma is one of the most important causes of death and disability in children, adolescents and young adults. Primary and secondary brain injuries are described based on a physiological view. A description of head trauma, and the most relevant issues of management are addressed. Controversial topics in the management of severe trauma with emphasis in monitoring, intra-cranial pressure, cerebral perfusion pressure, tissue oxygen pressure, mannitol, hypertonic sodium solution and hypothermia are covered. Future challenges as magnetic resonance imaging intrauma evaluation, monitoring and measurement of intracerebral metabolites, the use of Doppler in the assessment of cerebral blood flow regulation, measure of an index of vascular reactivity and using continuous EEG are discussed.

Do children with Glasgow 13/14 could be identified as mild traumatic brain injury?

OBJECTIVE: To identify in mild head injured children the major differences between those with a Glasgow Coma Scale (GCS) 15 and GCS 13/14. METHOD: Cross-sectional study accomplished through information derived from medical records of mild head injured children presented in the emergency room of a Pediatric Trauma Centre level I, between May 2007 and May 2008. RESULTS: 1888 patients were included. The mean age was 7.6 + or - 5.4 years; 93.7% had GCS 15; among children with GCS 13/14, 46.2% (p<0.001) suffered multiple traumas and 52.1% (p<0.001) had abnormal cranial computed tomography (CCT) scan. In those with GCS 13/14, neurosurgery was performed in 6.7% and 9.2% (p=0.001) had neurological disabilities. CONCLUSION: Those with GCS 13/14 had frequently association with multiple traumas, abnormalities in CCT scan, require of neurosurgical procedure and Intensive Care Unit admission. We must be cautious in classified children with GCS 13/14 as mild head trauma victims.

Do children with Glasgow 13/14 could be identified as mild traumatic brain injury? / Pacientes pediátricos com Glasgow 13 ou 14 podem ser identificados como traumatismo craniano leve?

OBJECTIVE: To identify in mild head injured children the major differences between those with a Glasgow Coma Scale (GCS) 15 and GCS 13/14. METHOD: Cross-sectional study accomplished through information derived from medical records of mild head injured children presented in the emergency room of a Pediatric Trauma Centre level I, between May 2007 and May 2008. RESULTS: 1888 patients were included. The mean age was 7.6±5.4 years; 93.7 percent had GCS 15; among children with GCS 13/14, 46.2 percent (p<0.001) suffered multiple traumas and 52.1 percent (p<0.001) had abnormal cranial computed tomography (CCT) scan. In those with GCS 13/14, neurosurgery was performed in 6.7 percent and 9.2 percent (p=0.001) had neurological disabilities. CONCLUSION: Those with GCS 13/14 had frequently association with multiple traumas, abnormalities in CCT scan, require of neurosurgical procedure and Intensive Care Unit admission. We must be cautious in classified children with GCS 13/14 as mild head trauma victims.

OBJETIVO: Identificar as principais diferenças entre os pacientes com Escala de Coma de Glasgow (GCS) 15 e aqueles com escore 13/14. MÉTODO: Estudo realizado por meio da revisão de prontuários médicos de crianças vítimas de traumatismo craniencefálico leve, admitidas em Centro de Urgências Pediátricas nível I, durante um ano. RESULTADOS: Incluídas 1888 vítimas; idade média de 7,6±5,4 anos; 93,7 por cento apresentaram pontuação 15 na GCS. Naqueles com pontuação 13/14, 46,2 por cento (p<0,001) sofreram traumas múltiplos e 52,1 por cento (p<0,001) apresentaram alterações na tomografia de crânio. Tratamento neurocirúrgico foi necessário em 6,7 por cento dos pacientes com GCS 13/14 e 9,2 por cento (p=0,001) apresentaram seqüelas neurológicas no momento da alta hospitalar. CONCLUSÃO: Crianças com escore 13/14 apresentam maior prevalência de traumas múltiplos, alterações na tomografia de crânio, necessidade de tratamento neurocirúrgico e internação em Unidade de Terapia Intensiva. Devemos ser cautelosos ao classificar crianças com pontuação 13/14 na GCS como vítimas de traumatismo craniano leve.

[Profile of motorcycle accident victims treated at a public hospital emergency department]. / Perfil das vítimas de trauma por acidente de moto atendidas em um serviço público de emergência.

The number of accidents involving motorcycles has increased in Brazil. The objective of this study was to identify the type of victims of these accidents who were treated at an emergency department in Piauí State, Brazil. The sample included 430 such victims in this quantitative study. Most were male, 15-24 years of age, and from the State of Piauí itself. 301 of the victims were drivers of the motorcycles, 81 were passengers, and 48 were struck or run over by the motorcycles. 76.05% of the accidents occurred from Thursday to Sunday. 80.75% had temporary sequelae, and 53.33% of the accidents occurred at night. In 69.3% of the cases, victims suffered lacerations; 51.4% fractures; 27.44% hematomas; and 20.7% head trauma. Among the accident victims, motorcycle drivers, and those suspected of alcohol consumption, 52.07% were not wearing a helmet at the time of the accident. Most of the victims were discharged from hospital, while 14 died. In conclusion, injuries from motorcycle accidents deserve attention, especially to plan preventive measures to help control their occurrence in the State.

Perfil das vítimas de trauma por acidente de moto atendidas em um serviço público de emergência / Profile of motorcycle accident victims treated at a public hospital emergency department

No Brasil, observa-se um aumento dos acidentes envolvendo motocicletas. Este estudo objetivou caracterizar as vítimas desse tipo de acidente atendidas em um serviço de emergência no Piauí. Pesquisa quantitativa com amostra de 430 vítimas. A análise mostrou predominância do sexo masculino, na faixa etária de 15 a 24 anos e procedentes do próprio estado. Observou-se que 301 dessas vítimas eram condutores da motocicleta, 81 passageiros e 48 foram atropelados por moto. Verificou-se que 76,05 por cento das vítimas sofreram acidente de quinta-feira a domingo, 80,75 por cento apresentaram seqüelas temporárias e 52,33 por cento dos acidentes ocorreram no período noturno. Os tipos de lesão corresponderam em 69,3 por cento dos casos a ferimentos; 51,4 por cento a fraturas; 27,44 por cento a hematomas; e 20,7 por cento a traumatismos cranioencefálicos. Entre as vítimas de acidente, condutores da moto e suspeitos de ingestão de álcool, 52,07 por cento não utilizavam capacete no momento do acidente. A maioria das vítimas recebeu alta hospitalar e 14 foram a óbito. Conclui-se que o trauma provocado pelos acidentes envolvendo motocicletas merece atenção, especialmente em relação ao planejamento de ações preventivas, assim como controle de sua ocorrência no estado.

The number of accidents involving motorcycles has increased in Brazil. The objective of this study was to identify the type of victims of these accidents who were treated at an emergency department in Piauí State, Brazil. The sample included 430 such victims in this quantitative study. Most were male, 15-24 years of age, and from the State of Piauí itself. 301 of the victims were drivers of the motorcycles, 81 were passengers, and 48 were struck or run over by the motorcycles. 76.05 percent of the accidents occurred from Thursday to Sunday. 80.75 percent had temporary sequelae, and 53.33 percent of the accidents occurred at night. In 69.3 percent of the cases, victims suffered lacerations; 51.4 percent fractures; 27.44 percent hematomas; and 20.7 percent head trauma. Among the accident victims, motorcycle drivers, and those suspected of alcohol consumption, 52.07 percent were not wearing a helmet at the time of the accident. Most of the victims were discharged from hospital, while 14 died. In conclusion, injuries from motorcycle accidents deserve attention, especially to plan preventive measures to help control their occurrence in the State.

[Pediatric victims of traffic accidents admitted to a university hospital: epidemiological and clinical aspects]. / Vítimas de acidentes de trânsito na faixa etária pediátrica atendidas em um hospital universitário: aspectos epidemiológicos e clínicos.

This study analyzes epidemiological and clinic characteristics of victims of traffic accidents. Data were obtained from medical records of children under 15 years of age (n = 1,123) admitted to a university hospital in Uberlândia, Minas Gerais State, Brazil, from 1999 to 2003. Mean age was eight years, 65.7% were boys, 76.6% were cyclists or pedestrians, 45.9% suffered head injuries, and 9% remained in hospital for more than two weeks. Fourteen (1.2%) died, 78.6% of these within 48 hours of hospitalization, and 85.7% with brain injuries. Among the passengers of motorcycles and larger vehicles, 58.8% were not using security devices properly at the time of the accident. Among the cyclists, 61% suffered isolated limb injuries. Meanwhile, pedestrians tended to suffer multiple lesions (57.5%) and be admitted to intensive care (7.1%), and represented 66.7% of the deaths. Epidemiological data on pediatric traffic victims can be useful for accident prevention programs.

Traumatismo encefalocraneano (TEC): una puesta al día / Craniocerebral Trauma (TEC): a bring up to date

El traumatismo encéfalocraneano continúa siendo la primera causa de muerte y discapacidad en la población de menos de 45 años de edad. Los datos obtenidos del Traumatic Coma Data Bank (TCDB), señalan que las cifras de malos resultados asociadas al TEC grave (pacientes que fallecen, que quedan en estado vegetativo o gravemente incapacitados), se acercan al 60 por ciento de los casos en los inicios de la década de los noventa. Su elevado índice de mortalidad, las prolongadas hospitalizaciones y las graves secuelas resultantes, hacen que el TEC constituya uno de los problemas socioeconómicos más importantes del momento actual. En los últimos años se han producido avances muy significativos tanto en el conocimiento de los mecanismos básicos del TEC como en su fisiopatología. Los nuevos conocimientos fisiopatológicos han permitido individualizar y racionalizar las medidas terapéuticas y han contribuido a mejorar el resultado final de estos pacientes. Por su gran interés práctico, y dado que la gran mayoría de estos enfermos son inicialmente atendidos por médicos de urgencia, cirujanos generales o internistas; parece recomendable explicitar cómo realizar una correcta evaluación neurológica en todo paciente que ha presentado un TEC, así como también exponer los mecanismos etiopatogénicos básicos involucrados en la génesis y evolución de las lesiones neurotraumáticas; y presentar los diferentes tipos de lesiones cerebrales de acuerdo con sus características radiológicas (lesiones focales y difusas), para finalmente diferenciar entre lesiones primarias, secundarias y terciarias, lo que nos permitirá comprender los fenómenos que tienen lugar en el momento del traumatismo, los que se añaden posteriormente y los que resultan de la acción de toda una serie de cascadas metabólicas anómalas que se desencadenan en este tipo de pacientes neurocríticos. En una mirada breve y actualizada del manejo del TEC, todavía persisten algunas sombras por aclarar, aunque las revisiones si...

Measurement of S-100B for risk classification of victims sustaining minor head injury--first pilot study in Brazil.

BACKGROUND: Release of the neuronal protein S-100B into the circulation has been suggested as a specific indication of neuronal damage. The hypothesis that S-100B is a useful and cost-effective screening tool for the management of minor head injuries was tested. METHODS: Fifty consecutive patients sustaining isolated minor head injury were prospectively evaluated in the emergency room of a Brazilian hospital by routine cranial computed tomography scan. Venous blood samples (processed to serum) were assayed for S-100B using a newly developed immunoassay test kit. Twenty-one normal healthy individuals served as negative controls. Data are presented as median and 25 to 75 percentiles. RESULTS: Patients reached the emergency room an average of 45 minutes (range: 30-62 minutes) after minor head injury. Six of 50 patients (12%) showed relevant posttraumatic lesions in the initial cranial computed tomography scan and were counted as positive. The median systemic concentration of S-100B in those patients was 0.75 microg/L (range: 0.66-6.5 microg/L), which was significantly different (U-test, P < .05) from the median concentration of 0.26 microg/L (range: 0.12-0.65 microg/L), of patients without posttraumatic lesions as counted by the cranial computed tomography. A sensitivity of 100%, a specificity of 20%, a positive predictive value of 15%, and a negative predictive value of 100% was calculated for the detection of patients suffering from intracranial lesions. CONCLUSIONS: Protein S-100B had a very high sensitivity and negative predictive value and could have an important role in ruling out the need for cranial computed tomography scan after minor head injury. This appears to be of substantial clinical relevance, particularly in countries where trauma incidence is high and medical resources are limited, such as in Brazil.

Measurement of S-100B for risk classification of victims sustaining minor head injury: first pilot study in Brazil

INTRODUÇÃO: A liberação da proteína neuronal S-100B na circulação tem sido sugerida como indicadora de dano neuronal. Foi testada a hipótese de que a S-100B é um marcador útil e custo efetivo para a triagem de pacientes com trauma craniano leve. MÉTODO: Cinqüenta pacientes consecutivos com trauma craniano isolado foram prospectivamente avaliados na sala de emergência de um Centro de Trauma brasileiro pela tomografia computadorizada de crânio e por amostras de sangue venoso, para a medida no soro da proteína S-100B utilizando um teste recentemente desenvolvido; 21 pessoas normais foram utilizadas como controles negativos. Os resultados são apresentados como mediana e percentis 25-75. RESULTADOS: Os pacientes chegaram ao Centro de Trauma em média 45 min (30-62) após o trauma craniano leve. Seis dos 50 pacientes tiveram lesões pós-traumáticas relevantes segundo a tomografia computadorizada de crânio inicial (12%) e foram considerados como positivos. A concentração mediana de S-100B nestes pacientes foi de 0,75µg/L (0,66-6,5), significativamente maior (U-teste, p<0,05) do que a concentração mediana de 0,26µg/L (0.12-0.65) dos pacientes sem lesões pós-traumáticas, segundo a tomografia computadorizada de crânioCCT-. O cálculo para a detecção dos pacientes com lesões intra-cranianas revelou sensibilidade de 100%, especificidade de 20%, valor preditivo positivo de 15% and valor preditivo negativo de 100%. CONCLUSÃO: A proteína S-100B tem altas taxas de sensibilidade e valor preditivo negativo, podendo ter um importante papel para descartar a necessidade de tomografia de crânio após trauma craniano leve. Acreditamos que este achado é de relevância clínica, principalmente em países onde o trauma é muito frequente e os recursos médicos limitados.

Factores pronósticos y evolución de pacientes con traumatismo craneoencefálico menor y moderado / Prognostic factors and evolution of patients whith complicated mild and moderate head trauma

Introducción: Muchos pacientes con traumatismo craneoencefálico leve o moderado complicados egresan actualmente de las unidades de terapia intensiva con pobres resultados. En relación con el tópico de los factores pronósticos, en estos casos existen muchas discrepancias relacionadas con el valor predictivo que algunos factores clínicos demográficos tienen en torno a la evolución de estos pacientes. La fuerza de la evidencia de las recomendaciones publicadas actualmente son insuficientes para su uso en nuestro medio. Métodos: Con el objetivo de evaluar el valor predictivo de algunas variables clínicas y demográficas en la evolución de pacientes con traumatismo craneoencefálico menor y moderado complicados, se realizó un estudio prospectivo de 109 pacientes atendidos con este diagnóstico entre el 1º de septiembre de 2001 y el 31 de abril de 2004 en la sala de cuidados intensivos de nuestro centro. Se estimó a través de un análisis univariado la asociación de cada variable por separado con la probabilidad que tiene un paciente con ese diagnóstico de egresar con una mala evolución. Resultados: los pacientes co edades por encima de 45 años (RR 2.7) los que presentaron hipotensión arterial (RR 1.9) y/o un Glasgow menor de 5 puntos en el momento de la admisión en la sala de cuidados intensivos (RR 2.5), presentaron un riesgo relativo significativamente mayor de 1 de egresar con una mala evolución. La mortalidad por traumatismo craneoencefálico leve fue de 0.12% y por traumatismo craneoencefálico moderado 53.71%. Conclusiones: Las variables estudiadas muestran una exactitud aceptable para la predicción de la evolución de pacientes con traumatismo craneoencefálicos menor o moderado complicados.