Luis Fernando Andrade de Carvalho – TCE Sinais de alerta e conduta

Transcrição

TCE
Sinais de alerta e conduta
Luis Fernando Andrade de Carvalho
Hospital Infantil João Paulo II
Hospital Mater Dei
Criança com 3 anos vítima de queda da própria altura, sem perda de
consciência, sem vômitos, com cefaléia leve e céfalo-hematoma
região frontal esquerda.
Radiat Environ Biophys. 2015 Mar;54(1):1-12. doi: 10.1007/s00411-014-0580-3. Epub 2015 Jan 8.
Risk of cancer incidence before the age of 15 years after exposure
to ionising radiation from computed tomography: results from a
German cohort study.
Krille L1, Dreger S, Schindel R, Albrecht T, Asmussen M, Barkhausen J, Berthold JD, Chavan A, Claussen C,
Forsting M, Gianicolo EA, Jablonka K, Jahnen A, Langer M, Laniado M, Lotz J, Mentzel HJ, Queißer-Wahrendorf
A, Rompel O, Schlick I, Schneider K, Schumacher M, Seidenbusch M, Spix C, Spors B, Staatz G, Vogl T, Wagner
J, Weisser G, Zeeb H, Blettner M.
J Trauma Acute Care Surg. 2014 Feb;76(2):292-5; discussion 295-6. doi: 10.1097/TA.0000000000000119.
Routine repeat brain computed tomography in all children with mild
traumatic brain injury may result in unnecessary radiation
exposure.
Howe J1, Fitzpatrick CM, Lakam DR, Gleisner A, Vane DW.
Ann Emerg Med. 2014 Aug;64(2):145-52, 152.e1-5. doi: 10.1016/j.annemergmed.2014.01.030. Epub 2014 Mar 11.
Comparison of PECARN, CATCH, and CHALICE rules for
children with minor head injury: a prospective cohort study.
Easter JS, Bakes K2, Dhaliwal J3, Miller M3, Caruso E2, Haukoos JS4
•
Identificar lesões cerebrais traumáticas clinicamente importantes (morte,
neurocirurgia, intubação maior que 24h, internação maior que 2 noites)
•
Experiência do medico e PECARN - 100% sensibilidade e 50% e
62% especificidade
•
CATCH 91% sensibilidade e 44% especificidade
•
CHALICE 84% sensibilidade e 85% especificidade
estudo foram submetidas
à TC de crânio.
Assim,
não
há
pacientes pediátricos com TCE100.0%
leve.
Medicine
(Stiell),
University
of
sensitive (95% CI 86.2%–100.0%)
for predicting
não
ficando
claro
o
motivo.
baseada
em sete achados,
que
são
divididos
em
alto
e
Pediatrics
como saber
se would
algumasrequire
crianças deste
grupo(Klassen,
sem TCMcConnell),
de
the need for neurologic intervention
and
Clinical
Research Unit
(Correl
Necessidade
de
vali
baixo risco
(Tabelaachados
1). that
Principais
desse
estudo
crânio
apresentavam
intracraniana
30.2%
of patients undergo
CT. The
medium-riskalguma
fac- 3 -lesão
Research
Institute,
Ottawa,
Ont
CMAJ
tors
resulted
in
98.1%
sensitivity
(95%
CI
94.6%–99.4%)
assintomática.
Uma
ferramenta
clínica
para
a
decisão
do
uso
of Toronto,
Toronto, O
prática clínica versity
e avaliar
o impacto
Pacientes com pelo menos um dos fatores de
for TCE
the leve
prediction
of brain
wouldcrianças
require foramUniversity
- Algumas
excluídasofdoWestern
estudo,
de TC de crânio em crianças com
foi proposta
e injury by CT2and
Ontario,
4
Uma
ferramenta
com
alto
risco
apresentaram
alto
risco
de
intervenção
(Bailey), CHU Sainte-Justine,
M
that
of patients
nãoCT.
ficando claro o motivo.
baseada em sete achados, que
são52.0%
divididos
em altoundergo
e
(Chauvin-Kimoff), McGill
Unive
com baixa
especificidade
levando
neurocirúrgica,
de validar
esta
ferramenta
na
baixo risco (Tabela 1).com uma sensibilidade de 100% 3e- Necessidade
Medicine (Pusic), Columbia Un
Interpretation:
The
decision
rule
developed
in
this study
CATCH:
a
clinical
decision
rule
for
the
use
of
computed
prática
clínica
e
avaliar
o
impacto
sócio
econômico.
Pacientes
pelo menos
um dosa fatores
de
Department
of Pediatrics
(Nijs
51,9%
das crianças
com
TCE leve
especificidade
decom
70,2%,
levando
indicação
deofTC
deOnce the
identifies
children
at two levels
risk.
decision
Alta.;
the Department
4 - injury
Uma ferramenta com alta
sensibilidade,
masof Pedi
in
children
with minor head
alto riscotomography
apresentaram alto
risco de intervenção
rule has been prospectively validated, it has the
potential
0,5%
dos
pacientes
necessitarão
crânio
em
30,2%
dos
pacientes.
Man.;de
andTC
theem
Departmed
com baixa especificidade levando à nipeg,
indicação
neurocirúrgica, com uma sensibilidade de 100% e
standardize and improve the use of CT for children with
Halifax, NS. The other members
e
de
que
apenas
4Head
a 7%
apresenta
A presença
deto
pelo
menos
um
dos
fatores
de
51,9% das
crianças
com
TCE leve,
a(PERC)
despeito
de
apenas
especificidade
de 70,2%, levando
a
indicação
de
TC
de
Injury Study Group
minor head injury.
0,5%
dosde
pacientes
necessitarão
crânio
30,2%H.dos
pacientes.
Martin
Osmond
MD CM, Terry P. Klassen
MD,
George
A. Wells
PhD,
Rhonda
Correll RN,de intervenção cirúrgica
visível.
alto
ouembaixo
risco,
apresentou
uma
sensibilidade
CMAJ
DOI:10.1503/cma
Anna
Jarvis MD,
Gary menos
Joubert um
MD,dos
Benoit
BaileydeMD, Laurel
Chauvin-Kimoff
MDapresentarão
CM,
e de que
apenas 4 a 7%
lesão2010.
intracraniana
A presença
de pelo
fatores
Martin
Pusic MD, Don McConnell
MD, Cheri
MD, Norm
MD,
5 - Número
pequeno d
98,1%
especificidade
deuma
50,1%
na Nijssen-Jordan
identificação
de Silver MD, Brett Taylor
visível.
alto ou e
baixo
risco,
apresentou
sensibilidade
de
Ian G. Stiell MD; for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group
2 anos
(277),
com menores
apenasde23 ca
pacientes
com lesões
detectadas
com5a- Número
pequeno
de crianças
98,1% e especificidade
de intracranianas
50,1% na identificação
de
Previously
publishedintracranianas
at www.cmaj.ca
CMAJ
• MARCH
9,
2010
• 182(4)
2 anos (277),
com
apenas
23 casos
de lesão
cerebral, e a
com lesões
detectadas
a crânio
o
que
limita
a
generalização
TCpacientes
de crânio.
Isso leva
à indicação
de com
TC de
em
Canadian Medical
Association nos
or itsresultalicensors
o que limita© a2010
generalização
e a confiança
TC de
crânio.
Isso levacom
à indicação
de aTC15de crânio em
3866
pacientes
ECG 13
ach year more than 650
000 children are seen in hosdos.
51,9%
dos
pacientes.
Abstract
dos.
51,9% dos
pacientes.
DOI:10.1503/cmaj.091421
Research
E
pital emergency departments in North America with
TC em 2043 pacientes (52,8%)
Background: There is controversy about which children with
“minor head injury,” i.e., history of loss of consciousminor
head injury need
undergo
computed-tomography
Lesões
cerebrais
emto 159
(4,1%)
neurocirurgia
24or (0,6%)
ness, em
amnesia
disorientation in a patient who is conscious
(CT). We aimed to develop a highly sensitive clinical decision
rule for the use of CT in children with minor head injury.
and responsive in the emergency department (Glasgow Coma
Scale score1 13–15). Although most patients with minor head
Tabela 1 - Methods:
Fatores
e baixo
risco
para
presença
injury intracraniana.
can be discharged after a period of observation, a small
For de
this alto
multicentre
cohort
study,
we a
enrolled
con- de lesão
Tabela 1 -secutiveFatores
deblunt
alto
baixo
riscowith
para
aproportion
presença
de lesão
intracraniana.
children with
headetrauma
presenting
a
experience
deterioration
of their condition and
of 13–15 on the Glasgow Coma Scale and loss of conneed to undergo neurosurgical intervention for intracranial
Alto risco score
sciousness, amnesia, disorientation, persistent vomiting or irrihematoma.2–4 The use of computed tomography (CT) in the
child, staff
in the
emergency
department
- Escala
detability.
comaFor
deeach
Glasgow
< 15
duas
horas após
o trauma emergency department is important in the early diagnosis of
Alto
risco
completed a standardized assessment form before any CT.
these intracranial hematomas.
- SuspeitaThe
de main
fratura
aberta
ouneed
afundamento
outcomes
were
for neurologic intervention
Over the past decade the use of CT for minor head injury has
and
ofde
brain
injury as determined
CT. We develHistóricode
depresence
piora da
cefaléia
- - Escala
coma
Glasgow
< 15by duas
horas após
traumacommon, while its diagnostic yield has
become o
increasingly
oped a decision rule by using recursive partitioning to comIrritabilidade
aofratura
exame
remained low. In Canadian pediatric emergency departments
binede
variables
that were
both reliable
strongly associated
- - Suspeita
aberta
ouandafundamento
the use of CT for minor head injury increased from 15% in 1995
with the outcome measures and thus to find the best combiRisco
nations
predictorda
variables
that were highly sensitive for
to 53% in 2005.5,6 Despite this increase, a small but important
- Baixo
Histórico
deofpiora
cefaléia
detecting the outcome measures with maximal specificity.
number of pediatric intracranial hematomas are missed in CanaQualquer
sinal
de
fratura
da
base
do
crânio
- Irritabilidade
ao exame
dian emergency departments at the first visit.3 Few children with
Results: Among the 3866 patients enrolled (mean age 9.2
- Hematoma
subgaleal volumoso
minor head injury have a visible brain injury on CT (4%–7%),
years), 95 (2.5%) had a score of 13 on the Glasgow Coma
and onlyde0.5%
intracranial
lesion requiring
urgent sem
neu- capacete)
Scale,de
282trauma
(7.3%) had
a score of
14, and 3489
(90.2%) had
- Mecanismo
perigoso
(acidente
automobilístico,
queda
1 mhave
ouanmais
ou 5 degraus,
bicicleta
Baixo
Risco
5,7
rosurgical intervention. The increased use of CT adds substana score of 15. CT revealed that 159 (4.1%) had a brain
injury, and 24 (0.6%) underwent neurologic intervention.
tially to health care costs and exposes a large number of children
- Qualquer
sinal
de
fratura
da
base
do
crânio
We derived a decision rule for CT of the head consisting of
to the
potentially harmful effects of ionizing radiaRev. Col. Bras. Cir. each
2013;year
40(6):
515-519
four high-risk factors (failure to reach score of 15 on the
8,9
ap
Identification of children at very low risk of
clinically-important brain injuries after head trauma:
a prospective cohort study
Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Jr, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe,
Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeﬀ E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein,
Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman,
Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean,
Sandra L Wootton-Gorges, for the Pediatric Emergency Care Applied Research Network (PECARN)*
Summary
Lancet 2009; 374: 1160–70
Published Online
PECARN
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
•
•
•
•
Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was toPublished
identify Online
children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
September 15, 2009
DOI:10.1016/S0140-
Methods We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow
Coma
6736(09)61558-0
Scale scores of 14–15 in 25 North American emergency departments. We derived and validated age-specific prediction
See Comment
page 1127
≥2 nights).
rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission
See Comment page 1127
Crianças
menores 18 anos nas primeiras 24h de trauma
*Members listed at end of paper
Departments of
Emergency Medicine
(Prof N Kuppermann MD,
Prof J F Holmes MD),
Pediatrics (Prof N Kuppermann),
Neurological Surgery
(Prof J P Muizelaar MD),
Surgery (Prof D H Wisner MD),
and Radiology
(Prof S L Wootton-Gorges MD),
University of California, Davis
School of Medicine, Davis, CA,
USA; Department of Pediatrics,
Columbia University College of
Physicians and Surgeons,
New York, NY, USA
(P S Dayan MD); Division of
Emergency Medicine, Michigan
State University School of
Medicine/Helen DeVos
Children’s Hosp, Grand Rapids,
MI, USA (J D Hoyle MD);
Departments of Pediatrics and
Emergency Medicine, George
Washington University School
of Medicine, Washington, DC,
USA (S M Atabaki MD);
Lancet 2009; 374: 1160–70
Findings We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger
than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred
Departments of
in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction ruleEmergency
for childrenMedicine
younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness
loss of
(Prof Nor
Kuppermann
MD,
consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally
according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7–100·0) and
Pediatrics
sensitivity of 25/25 (100%, 86·3–100·0). 167 (24·1%) of 694 CT-imaged patients younger than
2 years(Prof
wereNinKuppermann),
this
Neurological
low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, Surgery
no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) (Prof
had aJ negative
P Muizelaar MD),
predictive value of 3798/3800 (99·95%, 99·81–99·99) and sensitivity of 61/63 (96·8%, 89·0–99·6).
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in
and Radiology
validation populations.
Excluídos mecanismos de traumas leves como queda da própria altura sem
outros sinais ou sintomas diferentes de abrasões ou lacerações.
ECG 14 ou 15 - em 25 unidades de urgência americanas
Regras para predizer TCE clinicamente importante
•
TCEci
noites)
University
California, Davis
Interpretation These validated prediction rules identified children at very low risk of ciTBIs for whom
CT canofroutinely
School
of Medicine,
(morte,
neurocirurgia, intubação por mais 24h, internação
por
maisDavis,
de CA,
2
be obviated.
Bureau,
and the
Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health
Columbia
University
College of
Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US
Department of Health and Human Services.
New York, NY, USA
S Dayan
MD); Division
of
need acute intervention, and some are(Pfalse
positives
or
Introduction
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
Metho
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
ap
Summary
Lancet 2009; 374: 1160–70
Published Online
PECARN
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
identify Online
September 15, 2009
DOI:10.1016/S0140-
Coma
6736(09)61558-0
See Comment
page 1127
≥2 nights).
42.412
crianças
•
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
Lancet 2009; 374: 1160–70
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
•
Tomografia em 14.969 (35,3%) - 780 com lesões traumáticas (5,2%)
•
TCEci em 376 (0,9%) - neurocirurgia em 60 (0,1%)
•
Intubações por mais de 24h - 8 pacientes
•
Internações em 3.821 (9,0%)
•
Nenhum óbito
University
California, Davis
CT canofroutinely
be obviated.
Bureau,
and the
Columbia
University
College of
New York, NY, USA
S Dayan
MD); Division
of
positives
or
Introduction
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
Metho
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
•
Lancet 2009; 374: 1160–70
Summary
Crianças
menores 2 anos
identify Online
Lancet 2009; 374: 1160–70 Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was toPublished
•
Published Online
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
Summ
Backg
childr
September 15, 2009
See Comment
page 1127
≥2 nights).
Sem
céfalo-hematoma (exceto frontal)
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
•
Sem perda de consciência ou perda menor que 5 segundos
•
Mecanismo de trauma não grave
•
Sem fratura de crânio palpável
University
California, Davis
CT canofroutinely
be obviated.
• VPN 100% (1.176/1.176) e sensibilidade 100% (25/25) para TCEci
Bureau,
and the
Columbia
University
College of
• 167 (24,1%) das 694 TCs em menores de 2 anos eram desse grupo New York, NY, USA
S Dayan
MD); Division
of
positives
or
Introduction
•
Nathan
Rachel
Kathlee
Arthur
Sandra
DOI:10.1016/S0140Metho
Nível consciência
normal
Methods We enrolled
patients younger than 18 years presenting within 24 h of head trauma with Glasgow
Coma
6736(09)61558-0
•
ap
Comportamento normal segundo os pais
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
•
Crianças
menores 2 anos
identify Online
Lancet 2009; 374: 1160–70 Background CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was toPublished
•
Published Online
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
•
•
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
September 15, 2009
DOI:10.1016/S0140Metho
(risco
4,4%) within 24 h of head trauma with Glasgow
Nível consciência
normal
Methods We enrolled
patients younger
thanTCEci
18 years presenting
Coma
6736(09)61558-0
•
Lancet 2009; 374: 1160–70
Summary
ap
See Comment
page 1127
≥2 nights).
Sem
céfalo-hematoma (exceto frontal)
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
(risco TCEci 0,9%)*Members listed at end of paper
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
Scale
rules
•
Findin
Sem perda de consciência ou perda menor que 5 segundos (risco TCEci 0,9%)
•
(risco TCEci 0,9%)
•
Sem fratura de crânio palpável
(risco TCEci 4,4%)
•
Comportamento normal segundo os pais
S L Wootton-Gorges MD),
(risco TCEci 0,9%)(Prof
Interpretation These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely
be obviated.
VPN 100% (1.176/1.176)
e
sensibilidade
100%
(25/25)
para
TCEci
Funding The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the
167 (24,1%) das 694 TCs em menores de 2 anos eram desse grupo
Introduction
New York, NY, USA
S Dayan
MD); Division
of
positives
or
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
•
Summary2
maiores
Crianças
Lancet 2009; 374: 1160–70
•
Published Online
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
identify Online
September 15, 2009
See Comment
page 1127
≥2 nights).
Sem
perda de consciência
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
•
Sem vômitos
•
•
Sem sinais de fratura de base de crânio
University
California, Davis
CT canofroutinely
be obviated.
• VPN 99.95% (3.798/3.800) e sensibilidade 96,8% (61/63) para TCEci
Bureau,
and the
Columbia
University
College of
• 446 (20,1%) das 2.223 TCs em maiores de 2 anos eram desse grupo New York, NY, USA
S Dayan
MD); Division
of
positives
or
Introduction
•
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
DOI:10.1016/S0140Nivel consciencia
normal
Metho
Methods We enrolled
patients younger than 18 years presenting within 24 h of head trauma with Glasgow
Coma
6736(09)61558-0
•
anos
Lancet 2009; 374: 1160–70
ap
Sem cefaléia grave
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
•
Summary2
maiores
Crianças
Lancet 2009; 374: 1160–70
•
Published Online
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
anos
identify Online
September 15, 2009
See Comment
page 1127
≥2 nights).
Sem
perda de consciência
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
(risco TCEci 0,9%)
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
•
Sem vômitos
•
•
Sem sinais de fratura de base de crânio
(risco TCEci 0,9%)
(risco TCEci 0,9%)
(risco TCEci 4,3%)
University
California, Davis
CT canofroutinely
be obviated.
• VPN 99.95% (3.798/3.800) e sensibilidade 96,8% (61/63) para TCEci
Bureau,
and the
Columbia
University
College of
• 446 (20,1%) das 2.223 TCs em maiores de 2 anos eram desse grupo New York, NY, USA
S Dayan
MD); Division
of
positives
or
Introduction
•
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
DOI:10.1016/S0140Nivel consciencia
normal
Metho
TCEci
4,3%)
Methods We enrolled
patients younger(risco
than 18 years
presenting
within 24 h of head trauma with Glasgow
Coma
6736(09)61558-0
•
Lancet 2009; 374: 1160–70
ap
Sem cefaléia grave
(risco TCEci 0,9%)
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
ap
Summary
Lancet 2009; 374: 1160–70
identify Online
Pontos fortes
September 15, 2009
Lancet 2009; 374: 1160–70
Published Online
September 15, 2009
DOI:10.1016/S01406736(09)61558-0
DOI:10.1016/S0140-
Coma
6736(09)61558-0
See Comment
page 1127
≥2 nights).
1 - Foram excluídos os pacientes com ECG < 14 (TC alterada em 20% dos pacientes),
*Members listed at end of paper e com mecanismo de lesão de muito baixo risco.
assintomáticos
Departments of
Emergency Medicine
and Radiology
New York, NY, USA
Departments of
loss of
(Prof Nor
Kuppermann
MD,
Pediatrics
2 years(Prof
wereNinKuppermann),
this
Neurological
had aJ negative
P Muizelaar MD),
446(Prof
(20·1%)
of
Surgery
D H Wisner
MD),
and Radiology
2 - Estudo multicêntrico, com grande número de pacientes e prospectivo.
•
Permitindo análise de uma população de crianças com idade inferior a 2 anos
3 - O estudo estabelece um algoritmo eficaz e de fácil aplicabilidade na prática clínica.
4 - O desfecho final é o TCEci, o que impede a perda de pacientes em que TC de crânio não
foi sensível para o diagnóstico mas clinicamente o TCE trouxe repercussões (Prof
(concussões).
S L Wootton-Gorges MD),
University
California, Davis
CT canofroutinely
be obviated.
Bureau,
and the
Columbia
University
College of
New York, NY, USA
S Dayan
MD); Division
of
positives
or
Introduction
Nathan
Rachel
Kathlee
Arthur
Sandra
Summ
Backg
childr
Metho
Scale
rules
Findin
than 2
in 376
young
consc
accord
sensit
low-ri
no vo
predic
2223
valida
risco adequada, trazendo assim benefícios aos pacientes
(menor incidência de radiação ionizante) e ao sistema de
saúde (economia de recursos).
Crianças menores 2 anos
13·9% da população
4·4% risco TCEci
0·9% risco de TCEci
<0·02% risco de TCEci
Tabela 4 -
Crianças com idade inferior a 2 anos.
Tabela
álico leve
Crianças maiores 2 anos
ção de
cientes
ema de
14% da população
4·3% risco TCEci
0·9% risco de TCEci
<0·05% risco de TCEci
519
Computed Tomography of the Head in Children with Mild
Traumatic Brain Injury
Home (/;jsessionid=limiassso6sg.alice) / The American Surgeon (/content/sesc/tas;jsessionid=limiassso6sg.alice), Volume 80, Number 9
The American Surgeon, Volume 80, Number 9, September 2014, pp. 841-843(3)
Computed Tomography
of the Head in Children with Mild
Traumatic Brain Injury
Authors: Mihindu, Esther; Bhullar, Indermeet; Tepas, Joseph; Kerwin, Andrew
Source: The American Surgeon
(/content/sesc/tas;jsessionid=limiassso6sg.alice), Volume 80, Number 9,
September 2014, pp. 841-843(3)
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Entre 2008 e 2010 - 493 crianças com TCE e ECG 14 ou 15 com TC
91%
das
TCs
normais
(447)
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Usando PECARN - 178 (36%) não fariam TC, todas normais
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Abstract:
Pediatric Emergency Care Applied Research Network (PECARN) guidelines have a near 100 per cent negative predictive value for clinically important traumatic brain
(ciTBI) in children with mild head injury (Glasgow Coma Score [GCS] 14 or 15). Our goal was to retrospectively apply their criteria to our database to determine the po
impact on the rates of unnecessary head computed tomography (CT) and ciTBI detection. The records of pediatric patients with GCS 14 to 15 that had a head CT for
Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15.
Pediatric Emergency Care Applied Research Network head injury
clinical prediction rules are reliable in practice.
Schonfeld D1, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE.
EUA e Itália - 2.439 crianças com TCE e ECG 14 ou 15
•
959 crianças menores 2 anos (39%)
•
373 fizeram TC (15%)
•
69 com lesão intracraniana (3%)
•
19 pacientes com TCEci (0,8%)
•
PECARN - nenhuma criança com TCEci foi classificada como
baixo risco
NATURE REVIEWS | NEUROLOGY
blishers Limited. All rights reserved
in these indivias well as TAR
tion, have been
approximately
contact sports
itic Aβ plaques
been found in
single episode
DP-43 deposiesting that this
nguish patients
rom those with
s
t contact with
d its composioccur in this
be considered
VOLUME 9 | APRIL 2013 | 201
FOCUS ON TRAUMATIC BRAIN INJURY
VOLUME 9 | APRIL 2013 |
© 2013 Macmillan Publishers Limited. All rights reserved
Biomarkers of mild traumatic brain injury
in cerebrospinal fluid and blood
FOCUS
ON
TRAUMATIC
BRAIN
INJURY
Henrik Zetterberg,
Douglas
H.
Smith
and
Kaj
Blennow
Biomarkers of mild traumatic brain injury
in cerebrospinal fluid and blood
Abstract | Mild traumatic brain injury (TBI), which is defined as a head trauma resulting in a brief loss of
consciousness and/or alteration of mental state, is usually benign, but occasionally causes persistent and
Henrik
Zetterberg,
DouglasWhether
H. Smithaand
Kaj Blennow
sometimes
progressive
symptoms.
threshold
for the amount of brain injury and/or individual
vulnerability
might contribute to the development of these long-term consequences is unknown. Furthermore,
Abstract | Mild traumatic brain injury (TBI), which is defined as a head trauma resulting in a brief loss of
reliable diagnostic
methods
that
can establish
whether
a blow
tobenign,
the head
affectedcauses
the brain
(and in and
consciousness
and/or
alteration
of mental
state, is
usually
buthas
occasionally
persistent
what way)sometimes
are lacking.
In this Review,
we discuss
potential
biomarkers
of injury
to different
structures
and
progressive
symptoms.
Whether
a threshold
for the amount
of brain
injury and/or
individual
cell typesvulnerability
in the CNS might
that can
be detected
in body fluids.
present
arguments
in support
of the
need
for
Axon
contribute
to the development
of We
these
long-term
consequences
is unknown.
Furthermore,
terminals
further development
and validation
of such
and for
theirtouse
in assessing
patients
with(and
head
reliable diagnostic
methods that
can biomarkers,
establish whether
a blow
the head
has affected
the
brain
in
NSE,
SBPs
Tau
trauma inwhat
whom
theare
brain
might
been affected.
Specifically,
we focus of
oninjury
the need
for such
biomarkers
way)
lacking.
In have
this Review,
we discuss
potential biomarkers
to different
structures
and
and
UCH-L1
NFL
protein
cell types inof
the
CNS that can be
detected inthe
body
fluids.
We present
arguments
in support
of individuals,
the need for to
in the management
sports-related
concussion,
most
common
cause
of mild TBI
in young
further development
and
validationdue
of such
biomarkers,
for their use inblows
assessing
prevent long-term
neurological
sequelae
to concussive
orand
subconcussive
to thepatients
head. with head
trauma in whom the brain might have been affected.
Dendrites
Axon Specifically, we focus on the need for such biomarkers
Zetterberg, H. et al. Nat. Rev. Neurol. 9, 201–210 (2013); published online 12 February 2013; doi:10.1038/nrneurol.2013.9
in the management of sports-related concussion, the most common cause of mild TBI in young individuals, to
prevent long-term neurological sequelae due to concussive or subconcussive blows to the head.
Introduction
et al.result
Nat. Rev.
9, 201–210
(2013);
published online
February
doi:10.1038/nrneurol.2013.9
A blow toZetterberg,
the headH.can
inNeurol.
anything
from
a superThe12detection
of brain
injury in individuals who have
Myelin
sheath
MBP 2013;
Soma
ficial skin laceration to severe brain injury. The extremes
experienced a concussive or subconcussive blow to the
Introduction
of this range are easy to recognize by clinical examinahead is of particular relevance in sports such as boxing,
A blow to the head can result in anything from a superdetection of brain injury in individuals who have
tion and neuroimaging, but whether the brain has beenS100-B
hockey,The
rugby
and American football. Head injuries are
ficial skin laceration to severe brain injury. The extremes
experienced a concussive or subconcussive blow to the
injured by a blow to the head (in the presence of non-GFAPcommon in players of these sports, and several
athletes’
of this range are easy to recognize by clinical examinahead is of particular relevance in sportsAmyloid
such as boxing,
specific symptoms
such as dizziness, nausea or headache)Interleukins
careers
have ended because offootball.
chronicHead
neurological
plaques
tion and neuroimaging, but whether the brain has been
hockey, rugby and American
injuries are
6
and
cytokines
is more difficult
to
assess.
The
definition
of
mild
traumatic
or
psychiatric
symptoms.
An
objective
test
to athletes’
deterinjured by a blow to
the head (in the presence of noncommon in players of these sports, and several
Astroglial
1
brain injury
(TBI)
has changed
the past
60 years,
whether
an athlete
can
their sport
APPbecause
andsafely
amyloid-β
specific
symptoms
suchcell
asover
dizziness,
nausea
or headache)minecareers
have
ended
of return
chronictoneurological
6
but the American
Congress
of Rehabilitation
Medicine
highly desirable,
and would
is more difficult
to assess.
The definition of
mild traumaticwould,
or therefore,
psychiatricbesymptoms.
An objective
test toreduce
deter1
currently brain
defines
mild(TBI)
TBI has
as head
trauma
in
the current
over-reliance
oncan
CTsafely
scansreturn
(andtothe
associinjury
changed
over resulting
the past 60 years,
mine whether
an athlete
their
sport
one of thebut
following:
loss ofCongress
consciousness
for less than
exposure
to ionizing
radiation)
purpose
Capillary
the American
of Rehabilitation
Medicineated would,
therefore,
be highly
desirable,for
andthis
would
reduce
30 min, alteration
mental
state
up totrauma
24
h (being
group albumin
of
individuals
risk
of brain
injury
is
currently of
defines
mild
TBIfor
as head
resulting inAnother
the current
over-reliance
onatCT
scans
(and the
associCerebrospinal
fluid:serum
ratio
one of the
following: loss oforconsciousness
for for
less thanmilitary
ated personnel,
exposure towho
ionizing
radiation)
for this
purpose
dazed, confused
or disorientated),
loss of memory
might
be exposed
to several
2
7
30 min, alteration
ofafter
mental
for up to 24 h (beingtypesAnother
of individuals
at risk ofInbrain
injurytois
events immediately
before or
thestate
trauma.
of braingroup
trauma
in the battlefield.
addition
dazed,
confused
or concussion
disorientated),
or loss
of memory forbiomarkers
militaryfor
personnel,
who
might
exposedphases
to several
The terms
mild
TBI and
have
historically
use in the
acute
andbesubacute
of
2
7
Figure
1
|
Possible
biomarkers
of
traumatic
brain
injury.
These
molecules
include
events
immediately
before
or
after
the
trauma.
types
of
brain
trauma
in
the
battlefield.
In
addition
been used interchangeably to suggest an inconsequenmild TBI, development of biomarkers that will enableto
Clinical Neurochemistry
Laboratory, Institute of
Neuroscience and
Clinical Neurochemistry
Physiology, Department
41-6
CLINICS 2006;61(1):41-6
ORIGINAL RESEARCH
MEASUREMENT OF S-100B FOR RISK
CLASSIFICATION OF VICTIMS SUSTAINING MINOR
HEAD INJURY - FIRST PILOT STUDY IN BRAZIL
Luiz F Poli-de-Figueiredo a,b , Peter Biberthaler c , Charles Simao Filho d,
Christopher Hauserc, Wolf Mutschlerc, and Marianne Jochumc
Measurement of S-100B for risk classification of victims sustaining minor head injury
Poli de Figueiredo LF et al.
Poli de Figueiredo LF, Biberthaler P, Simao Filho C, Hauser C, Mutschler W, Jochum M. Measurement of S-100B for risk
victims
sustaining
injury 1
- first
pilot study in table
Brazil.ofClinics.
2006;61(1):41-6.
- Contingency
S-100B
measurements and
atientsclassification
with a GCSof of
15, 11
with aminor
GCSheadTable
h a GCS of 13. Out of these, 6 patients cranial computed tomography (CCT)-findings
BACKGROUND: Release of the neuronal protein S-100B into the circulation has been suggested as a specific indication of
ant intracranial
lesions
accordingthattoS-100B
the is a useful and cost-effective screening tool for the management of minor head
neuronal damage.
The hypothesis
CCT+
CCTinjuries
wasPatients
tested. and Methods secia given
in the
Fifty consecutive patients sustaining isolated minor head injury were prospectively evaluated in the emergency
35
positive predictive
ereby METHODS:
counted
as
CCT+. In contrast, 44 S-100B > 0.1 µg/L 6
room of a Brazilian hospital by routine cranial computed tomography scan. Venous blood samples (processed to serum) were
15%
e of these
lesions
and using
werea newly
counted
as immunoassay test kit. Twenty-one normal healthyvalue
assssayed
for S-100B
developed
individuals served as negative
S-100B < 0.1 µg/L 0
9
negative predictive
controls. Data are presented as median and 25 to 75 percentiles.
value 100%
RESULTS: Patients reached the emergency room an average of 45 minutes (range: 30–62 minutes) after minor head injury. Six of
ime interval
from trauma to blood samspecificity
50 patients (12%) showed relevant posttraumatic lesions in the initial sensitivity
cranial computed
tomography scan and were counted as
0B assay
was The
82 minutes
(25%-75%
quar- of S-100B in those patients
100%was 0.75
20%
positive.
median systemic
concentration
µg/L (range: 0.66–6.5 µg/L), which was
differentconcentration
(U-test, P < .05)of
from
concentration of 0.26 µg/L (range: 0.12–0.65 µg/L), of patients without
). Thesignificantly
median serum
S- the median
Sensitivity, specificity, positive, and negative predictive value for the
posttraumatic lesions as counted by the cranial computed tomography. A sensitivity of 100%, a specificity of 20%, a positive
distribution of pathological S-100B values and cranial computed tomography
g/L (25%-75%
quartiles:
µg/L)
predictive value
of 15%,0.14–0.76
and a negative
predictive value of 100% was calculated for the detection of patients suffering from
I group,
which lesions.
was significantly elevated (CCT) scan findings. Positive CCT scan (CCT+) represents signs of a relevant
intracranial
posttraumatic intracerebral pathology, eg, hemorrhage, diffuse brain
Protein S-100B
a very high sensitivity and negative predictive value and could have an important role in
ared toCONCLUSIONS:
that of the negative
controlhad
group
swelling, or skull fracture, whereas CCT- stands for the absence of trauma-
Acta Paediatr. 2009 Oct;98(10):1607-12. doi: 10.1111/j.1651-2227.2009.01423.x.
Neuroprotein s-100B -- a useful parameter in paediatric patients
with mild traumatic brain injury?
Castellani C1, Bimbashi P, Ruttenstock E, Sacherer P, Stojakovic T, Weinberg AM.
•
109 pacientes de 0 a 18 anos com TCE leve
•
Ponto de corte S100B de 0,16 mcg/L - coleta com 6h de trauma
•
Todos fizeram TC - alterada em 36 pacientes
•
Nenhum falso negativo, 42 falso positivos
•
Sensibilidade 100% e especificidade de 42% com VPN de 100%
Of the 424 Masters 1 or 2 children, 21 were included in
S100B to differentiate between bad CE and good CE in
the bad CE group. AsClinical
shown
in
Table
2,
measurement
Chemistry 58:7
Pediatric Clinical Chemistry
patients after mTBI.
1116–1122
(2012)
of S100B identified patients correctly as bad CE with a
sensitivity of 100% (CI, 84%–100%) and a specificity
of 36% (CI, 31%– 41%). With an area under the curve
0.19 !g/L. Of the 242 hospitalized children (Masters 1
value of 0.75 (CI, 0.70 – 0.79)
in the ROC
analysis
(Fig.
and 2), 81
were S100B". An of
S100B assay costs
Serum
S100B
Determination
in(33.5%)
the Management
2), S100B measurement was found Pediatric
to be a highlyMild
sig- Traumatic
US$44 and Brain
daily hospitalization
in France costs
Injury
nificant indicator for the correct stratification
of pa- 1 US$1587. Hence
a potential
saving of US$117
875 [(81
1
2
2
3
Damien Bouvier, Mathilde Fournier, Jean-Benoı̂t Dauphin, Flore Amat, Sylvie Ughetto,
tients with TBI into the bad
CE or good CE groups
nonhospitalized # US$1587) " (242 potentially hosAndré Labbé,2 and Vincent Sapin1*
(area under ROC curve ! 0.75; P ! 0.0001). The
pitalized patients # US$44)] could be made with no
best threshold conserving a sensitivity of 100% was
harm to patients.
BACKGROUND:
The place of serum S100B measurement
avoiding unnecessary irradiation, and to save hospitalin mild traumatic brain injury (mTBI) management is
ization costs.
still controversial.
prospective studyby
aimed
to eval2012 American Association for Clinical Chemistry
Table
2. S100BOur
concentration
CCT,
clinical©evolution,
and management.a
uate its utility in the largest child cohort described to
date.
Positive
Negative
Accidents are the major
cause of morbidity and
morS100B!
S100B"
Sensitivity
Specificity
predictive
value
predictive
value
METHODS: Children younger than 16 years presenting
tality in children, and head trauma is the injury most
at a pediatric emergency department within 3 h after
responsible 45%
for death.
Case series from
CCT%
23
0
100% (85.2%–100%)
33% often
(20%–50%)
(31%–60%)
100%multiple
(77%–100%)
TBI were enrolled prospectively for blood sampling
trauma centers report that 75% to 97% of trauma
CCT"
14 S100B concentrations. The folto 28
determine serum
deaths in children result from head injuries (1 ). The
lowing information was collected: TBI severity deof traumatic
injury (TBI)4100%
is calculated
Bad CE
21
0
100% (84%–100%)
36% incidence
(31%–41%)
8%brain
(5%–11%)
(97%–100%)
termined by using the Masters classification [1: minas 1/285 in babies younger than 1 year (2 ), and up to
Good CE
258 or Glasgow
145Coma Scale (GCS) 15, 2: mild or
imal
80% of deaths in children younger than 2 years are due
GCS 13–15, and 3: severe or GCS !13]; whether
to inflicted TBI. A study of severe fatal TBI in the US
Hospitalized
161
81
hospitalized or not; good or bad clinical evolution
found incidence figures similar to those for the UK, at
(CE);
computed tomography (CCT)
Nonhospitalized
118 whether cranial
64
approximately 1/3300 children age 0 –12 months (3 ).
was prescribed; and related presence (CCT") or abPatients with minimal or severe TBI are easy to recoga
sence (CCT#)
of lesions.
Patients exhibiting serum concentrations
below
the cutoff (0.35 !g/L for age 0 –9 months; 0.23
g/Lclinical
for age 10
–24 months;
0.18correct
!g/L fordiagnosis
age &24 months)
were
nize!in
practice,
but the
of
counted as S100B", and those above as S100B%. CCT": mTBI patients with no signs of trauma-relevant
intracerebral
lesions.
mTBIchildren
patients is
with at least
mild TBI (mTBI)
in babies
andCCT%:
younger
RESULTS: For
the 446 children
enrolled,
theofmedian
1 pathophysiological trauma–relevant
intracerebral
lesion. The
symptoms
bad CE weredifficult
vomiting,even
facialfor
paralysis,
movement
disorders,partly
vertigo,
experienced
physicians,
be-photomotor
concentrations
oforS100B
were
0.21,Good
0.31,CEand
reflex disorder, seizure, progressive
headache,
behavior
change.
was 0.44
indicated cause
by absence
of these symptoms.
Numbers
in parentheses
are 95% CIs.
questioning
rarely provides
a good
history of
!g/L in Masters groups 1, 2, and 3, respectively, with
trauma, and partly because infants present common
a statistically significant difference between these
nonspecific clinical symptoms. Current policy addressgroups (P ! 0.05). In Masters group 2, 65 CCT scans
ing this issue hinges on 2 strategies: routine cranial
Clinical
Chemistry
58:7
(2012)
1119
were carried out. Measurement of S100B identified
computed tomography
(CCT)
and discharge
in the
abpatients as CCT" with 100% (95% CI 85–100) sensence of symptoms, and inpatient observation for up to
sitivity and 33% (95% CI 20 –50) specificity. Of the
24 h and CCT in the event of clinical deterioration.
424 children scored Masters 1 or 2, 21 presented
Both approaches present drawbacks. CCT is associated
“bad CE.” S100B identified bad CE patients with
with exposure to ionizing radiation and sedation,
Clinical Chemistry 58:7
1116–1122 (2012)
Pediatric Clinical Chemistry
S100B Utility for mTBI in 446 Children
Serum S100B Determination in the Management of
Pediatric Mild Traumatic Brain Injury
Damien Bouvier,1 Mathilde Fournier,1 Jean-Benoı̂t Dauphin,2 Flore Amat,2 Sylvie Ughetto,3
André Labbé,2 and Vincent Sapin1*
BACKGROUND:
The place of serum S100B measurement
avoiding unnecessary irradiation, and to save hospitaland
in mild traumatic brain injury (mTBI)Interview
management
is clinical
ization costs.
still controversial. Our prospectiveexamina!on
study aimed to eval© 2012 American Association for Clinical Chemistry
of the child
uate its utility in the largest child cohort described to
leading to Masters classifica!on
date.
Accidents are the major cause of morbidity and morChildren younger than 16 years presenting
tality in children, and head trauma is the injury most
at a pediatric emergency department within 3 h after
often responsible for death. Case series from multiple
TBI were enrolled
prospectively
for blood sampling
Masters
1
Masters
Masters 22trauma centersMasters
3 75% to 97% of trauma
report that
to determine GCS
serum15S100B concentrations. The
folresult
GCS 13–15 deaths in children
GCS
<13from head injuries (1 ). The
lowing information was collected: TBI severity deincidence of traumatic brain injury (TBI)4 is calculated
termined by using the Masters classification [1: minas 1/285 in babies younger than 1 year (2 ), and up to
imal or Glasgow Coma Scale (GCS) 15, 2: mild or
80% of deaths in children younger than 2 years are due
GCS 13–15,
and 3: able
severe or GCS !13]; whether
Are parents
to inflicted TBI.
S100B measurement
if A study of severe fatal TBI in the US
hospitalized
or
not;
good
or
bad
clinical
evolution
found incidence figures similar to those for the UK, at
to provide home
mTBI
<3h
(CE); whether
cranial computed tomography (CCT)
approximately 1/3300 children age 0 –12 months (3 ).
monitoring?
was prescribed;
and to
related presence (CCT") or abPatients with minimal or severe TBI are easy to recogHome close
sence (CCT#)
of
lesions.
nize in clinical practice, but the correct diagnosis of
the hospital?
mild TBI (mTBI) in babies and younger children is
<
Reference
> Reference
RESULTS: For the 446 children enrolled, the median
difficult even for experienced physicians, partly belimitquestioning
limitand 0.44 cause
or mTBI rarely provides a good history of
concentrations of S100B were 0.21, 0.31,
!g/L in Masters groups 1, 2, and 3, respectively, with
3 h partly because infants present common
trauma,> and
YES
NO
a statistically significant difference between these
nonspecific clinical symptoms. Current policy addressgroups (P ! 0.05). In Masters group 2, 65 CCT scans
ing this issue hinges on 2 strategies: routine cranial
were carried out. Measurement of S100B identified
computed tomography (CCT) and discharge in the abpatients as CCT" with 100% (95% CI 85–100) sensence of symptoms, and
inpatient observation for up to
Hospitaliza!on
Hospitaliza!on
monitoring
Home
sitivity and 33% (95% CI 20 –50) specificity. Of the
24 h and CCT in the event of clinical deterioration.
and/or
CCT
and CCTCCT is associated
424 children scored Masters 1 or 2, 21 presented
Both
approaches present drawbacks.
“bad CE.” S100B identified bad CE patients with
with exposure to ionizing radiation and sedation,
METHODS:
ments of
erroneou
nal dama
should b
tion rega
S100B, a
formed a
child (24
could als
of new
hydrolas
kDa, whi
brain inj
of our de
ples for t
Diagnostic performance of S100B protein serum measurement in
detecting intracranial injury in children with mild head trauma.
Manzano S, Holzinger IB2, Kellenberger CJ3, Lacroix L et al
Emerg Med J. 2015 Aug 17
•
Estudo multicêntrico em 3 hospitais suíços 2009 a 2011
•
Crianças menores 16 anos com TCE leve (ECG 13 a 15) com solicitação de
TC pelo medico
•
Dosagem no sangue proteína S100B com 6h do trauma (resultado posterior
a condução clinica)
•
TC alterada em 20 de 73 crianças (27,4%)
•
Valor de corte S100B 0,14mcg/L
•
•
•
sensibilidade 95% todas as crianças e 100% maiores 2 anos
especificidade 34% e 37%
Ferramenta para descartar lesão intracraniana e reduzir TCs desnecessárias
In Children and Youth With Mild and Moderate Traumatic Brain
Injury GFAP Out-performs S100β In Detecting Traumatic
Intracranial Lesions On CT.
Papa L1, Mittal MK, Ramirez J, Ramia M, Kirby S, Silvestri S, Giordano P, Weber K, Braga CF, Tan CN, Ameli
NJ, Lopez M, Zonfrillo MR.
J Neurotrauma. 2015 Mar 9. •
Glial Fibrillary Acidic Protein (GFAP) x S100β
•
Coleta com 6 horas de trauma
•
155 crianças - 114 com TCE e 41 sem TCE
•
GFAP foi melhor para detectar TCE e lesão intracraniana na TC
JOURNAL OF NEUROTRAUMA 31:722–727 (April 15, 2014) a Mary Ann Liebert, Inc. DOI: 10.1089/neu.2013.3088
Prevalence of and Risk Factors for Poor Functioning after Isolated
Mild Traumatic Brain Injury in Children
Mark R. Zonfrillo,1 Dennis R. Durbin,1 Thomas D. Koepsell,2,8 Jin Wang,4,8 Nancy R. Temkin,3,5 Andrea M. Dorsch,6 Monica S.
Vavilala,4,7,8 Kenneth M. Jaffe,4–6,8 and Frederick P. Rivara2,4,8
•
Estudo prospectivo crianças menores 18 anos com TCE leve isolado (sem lesão
intracraniana)
•
Qualidade de vida basal x 3 meses x 12 meses após trauma
•
Redução maior que 15 pontos no basal
•
329 pacientes - 11,3% as 3 meses e 12,9% aos 12 meses apresentaram piora
•
Condição sócio-econômica
JOURNAL OF NEUROTRAUMA 31:722–727 (April 15, 2014) a Mary Ann Liebert, Inc. DOI: 10.1089/neu.2013.3088
Prevalence of and Risk Factors for Poor Functioning after Isolated
Mild Traumatic Brain Injury in Children
Mark R. Zonfrillo,1 Dennis R. Durbin,1 Thomas D. Koepsell,2,8 Jin Wang,4,8 Nancy R. Temkin,3,5 Andrea M. Dorsch,6 Monica S.
Vavilala,4,7,8 Kenneth M. Jaffe,4–6,8 and Frederick P. Rivara2,4,8
ZONFRILLO ET AL.
FIG. 1. (A) The distribution of the change in Pediatric Quality of Life Index (PedsQL) score between baseline and
injury. (B) The distribution of the change in PedsQL score between baseline and 12 months following injury.
Discussion
This large study of the prevalence and predictors of low PedsQL
tively, whereas those for subjects with poor o
and 66.1, respectively. This is comparable to
research in which parents’ subjective measurem
Neuropsychology. 2010 March ; 24(2): 148–159. doi:10.1037/a0018112.
Post-Concussive Symptoms in Children with Mild Traumatic Brain Injury
H. Gerry Taylor1,2, Ann Dietrich3,7, Kathryn Nuss3,7, Martha Wright1,2, Jerome Rusin5, Barbara Bangert6, Nori Minich1, and
Keith Owen Yeates3,4 •
PCS - cefaléia, tonteira, fadiga, depressão ou ansiedade, distúrbio do
sono, fotossensibilidade, dificuldade de concentração e deficit de
memória.
Taylor et al.
Page 18
Taylor et al.
Page 20
NIH-PA Author Manuscript
NIH-PA Author M
Figure 2.
Estimated mean parent ratings of cognitive PCS across follow-up for the mTBI and OI groups.
Figure 4.
Estimated mean child self-ratings of somatic PCS across follow-up for the mTBI and OI groups.
Neuropsychology. 2013 January ; 27(1): 1–12. doi:10.1037/a0031370.
Injury versus non-injury factors as predictors of post- concussive symptoms
following mild traumatic brain injury in children
Kelly A. McNally1,2, Barbara Bangert3, Ann Dietrich2,4, Kathy Nuss2,4, Jerome Rusin5, Martha Wright6,7, H. Gerry Taylor6,7, and
Keith Owen Yeates2,8
•
Fatores relacionados ao trauma - precoce
•
Fatores relacionados a criança e a família - tardio
Brain Inj. 2013;27(2):145-57. doi: 10.3109/02699052.2012.729286. Predictors of child post-concussion symptoms at 6 and 18 months following
mild traumatic brain injury.
Olsson KA1, Lloyd OT, Lebrocque RM, McKinlay L, Anderson VA, Kenardy JA.
•
Sintomas pre e pos trauma de PCS
•
Fatores relacionados a criança e a família - estresse familiar e cognição
Author Manuscript
JAMA Pediatr. 2013 February ; 167(2): 156–161. doi:10.1001/
jamapediatrics.2013.434.
Author Manuscript
Predicting Postconcussion
Syndrome After Mild Traumatic
Brain Injury in Children and
Adolescents Who Present to the
Emergency Department
Lynn Babcock, MD, MS, Terri Byczkowski, PhD, Shari L. Wade,
PhD, Mona Ho, MS, Sohug Mookerjee, BS, MPH, and Jeffrey J.
Bazarian, MD, MPH Maior risco de Sindrome pós-concussão em
pacientes com TCE leve
Author Manuscript
•
Cefaleia a admissão
•
Necessidade de internação
Pediatr Emerg Care. 2013 April ; 29(4): 458–461. doi:10.1097/PEC.0b013e31828a202d.
Inability of S100B to Predict Post-Concussion Syndrome in Children who Present to the
Emergency Department with Mild Traumatic Brain Injury: A Brief Report
Lynn Babcock et al
Critérios de internação
hospitalar
. TC de crânio e encéfalo alterada ou indisponível (se indicada). . História de perda de consciência por tempo superior a 5 minutos. . TCE penetrante ou presença de fratura de crânio à radiografia. . Cefaleia moderada a grave, otorreia, rinorreia. . Relato de amnésia prolongada. . Sinais de intoxicação por álcool ou drogas. . Ausência de um acompanhante confiável e impossibilidade de retornar rapidamente ao hospital caso seja necessário.
Orientações de alta hospitalar
•
Retorno imediato
•
Alterações no nível de consciência ou confusão mental
•
Sonolência
•
Cefaléia importante
•
Vômitos
•
Drenagem de liquor ou sangue pelo nariz ou ouvido
Obrigado!
[email protected]
[email protected]

Luis Fernando Andrade de Carvalho – TCE Sinais de alerta e conduta

Transcrição

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