Fatores associados à hipertensão intracraniana em crianças e adolescentes vítimas de traumatismo crânio-encefálico grave

Abstract

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. No conflicts of interest declared concerning the publication of this article.Suggested citation: Guerra SD, Carvalho LF, Affonseca CA, Ferreira AR, Freire HB. Factors associated with intracranial hypertension in children and teenagers who suffered severe head injuries. J Pediatr (Rio J). 2010;86(1):73-79.

Traumatic brain injury: causes and profile of victims attended to at an emergency health clinic in Pelotas, Rio Grande do Sul, Brazil

“…A escala de Glasgow é um método de avaliação neurológica confiável que tem como objetivo identificar, por meio de escore, o nível de consciência, o prognóstico da gravidade do traumatismo e eventuais sequelas. Essa escala avalia o paciente em três comandos: abertura ocular, resposta verbal e resposta motora, e seu escore final classifica o TCE em leve (13)(14)(15); moderado (9-12); e grave (3)(4)(5)(6)(7)(8). O máximo da escala é o 15 e o mínimo é o três.…”

Events Associated With the Occurrence of Intracranial Hypertension in Pediatric Patients With Severe Cranioencephalic Trauma and Monitoring of Intracranial Pressure

“…24 The predominance of male patients, aged between nine and ten years old and victims of traffic accidents, is in agreement with previous reports from Mexico, Brazil and South Africa. 10,11,25 The GCS score distribution at the time of admission and the PTS classifications show that this was a group of critically ill patients. Furthermore, the tomographic description that shows multiple injuries per individual reinforces the impression of the complexity of the trauma suffered.…”

“…Patients with no motor response, flexion posture or abnormal extension at the time of admission (GCS score of three to five) were grouped for analysis of the association with ICH, because these events have been associated with the occurrence of refractory ICH in previous studies. 11,16 Cranial computed tomography was performed at the time admission and repeated during treatment as needed. The tomographic findings were gathered into two groups.…”

“…The sample size calculation was based on a study of ICU patients between 1998 and 2003, where ICH occurred in 80% of the 134 monitored patients. 11 Considering the 95% confidence interval (95% CI), the 5% significance level and the 80% study power, the minimum sample size was 110 patients in whom factors associated with the occurrence of ICH were evaluated.…”

“…[7][8][9] In addition, monitoring has complications such as infections, bleeding, measurement errors and malfunctions, with variable frequency, depending on the device used. 8,10,11 Reports of prolonged mechanical ventilation, length of stay, unnecessary institution of harmful treatments, and increased hospital costs with and without ICP monitoring are also contradictory. 8,12,13 The recommendations for monitoring that are in the "Guidelines for the Clinical Treatment of Severe Head Injury in Infants, Children and Adolescents" are Level III of evidence, "therapeutic option".…”