Severe pediatric head injuries (I). Epidemiology, clinical manifestations and course

array:23 ["pii" => "S2173572711000178" "issn" => "21735727" "doi" => "10.1016/j.medine.2011.02.002" "estado" => "S300" "fechaPublicacion" => "2011-08-01" "aid" => "265" "copyright" => "Elsevier España, S.L. and SEMICYUC" "copyrightAnyo" => "2010" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Intensiva. 2011;35:331-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2014 "formatos" => array:3 [ "EPUB" => 129 "HTML" => 1319 "PDF" => 566 ] ] "itemSiguiente" => array:18 [ "pii" => "S2173572711000208" "issn" => "21735727" "doi" => "10.1016/j.medine.2011.02.005" "estado" => "S300" "fechaPublicacion" => "2011-08-01" "aid" => "270" "copyright" => "Elsevier España, S.L. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Med Intensiva. 2011;35:337-43" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2825 "formatos" => array:3 [ "EPUB" => 141 "HTML" => 1390 "PDF" => 1294 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Serious pediatric head injuries (II): factors associated to morbidity–mortality" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "337" "paginaFinal" => "343" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Traumatismo craneoencefálico pediátrico grave (II): factores relacionados con la morbilidad y mortalidad" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 806 "Ancho" => 1611 "Tamanyo" => 80483 ] ] "descripcion" => array:1 [ "en" => "Percentage distribution of the incidence and mortality of pediatric serious head injuries in the different periods of the study." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.M. López Álvarez, M.E. Valerón Lemaur, O. Pérez Quevedo, J.M. Limiñana Cañal, A. Jiménez Bravo de Laguna, E. Consuegra Llapurt, A. Morón Saén de Casas, R. González Jorge" "autores" => array:8 [ 0 => array:2 [ "nombre" => "J.M." "apellidos" => "López Álvarez" ] 1 => array:2 [ "nombre" => "M.E." "apellidos" => "Valerón Lemaur" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Pérez Quevedo" ] 3 => array:2 [ "nombre" => "J.M." "apellidos" => "Limiñana Cañal" ] 4 => array:2 [ "nombre" => "A." "apellidos" => "Jiménez Bravo de Laguna" ] 5 => array:2 [ "nombre" => "E." "apellidos" => "Consuegra Llapurt" ] 6 => array:2 [ "nombre" => "A." "apellidos" => "Morón Saén de Casas" ] 7 => array:2 [ "nombre" => "R." "apellidos" => "González Jorge" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000208?idApp=WMIE" "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000208/v1_201212101034/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S2173572711000233" "issn" => "21735727" "doi" => "10.1016/j.medine.2011.05.001" "estado" => "S300" "fechaPublicacion" => "2011-08-01" "aid" => "301" "copyright" => "Elsevier España, S.L. and SEMICYUC" "documento" => "article" "crossmark" => 0 "subdocumento" => "sco" "cita" => "Med Intensiva. 2011;35:328-30" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2650 "formatos" => array:3 [ "EPUB" => 156 "HTML" => 1835 "PDF" => 659 ] ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Editorial" "titulo" => "Towards the future in pediatric intensive care" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "328" "paginaFinal" => "330" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hacia el futuro en cuidados intensivos pediátricos" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Ocete Hita" "autores" => array:1 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Ocete Hita" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000233?idApp=WMIE" "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000233/v1_201212101034/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original" "titulo" => "Severe pediatric head injuries (I). Epidemiology, clinical manifestations and course" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "331" "paginaFinal" => "336" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J.M. López Álvarez, M.E. Valerón Lemaur, O. Pérez Quevedo, J.M. Limiñana Cañal, A. Jiménez Bravo de Laguna, E. Consuegra Llapurt, A. Morón Saén de Casas, R. González Jorge" "autores" => array:8 [ 0 => array:4 [ "nombre" => "J.M." "apellidos" => "López Álvarez" "email" => array:1 [ 0 => "jmloal@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M.E." "apellidos" => "Valerón Lemaur" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "O." "apellidos" => "Pérez Quevedo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "J.M." "apellidos" => "Limiñana Cañal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "A." "apellidos" => "Jiménez Bravo de Laguna" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "E." "apellidos" => "Consuegra Llapurt" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "A." "apellidos" => "Morón Saén de Casas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "R." "apellidos" => "González Jorge" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Medicina Intensiva Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Bioestadística, Facultad de Medicina, Las Palmas de Gran Canaria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Traumatismo craneoencefálico pediátrico grave (I). Epidemiología, clínica y evolución" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 944 "Ancho" => 1597 "Tamanyo" => 59102 ] ] "descripcion" => array:1 [ "en" => "Percentage distribution of the GCS score in the pediatric patients with SHIs." ] ] ] "textoCompleto" => "IntroductionHead injuries (HIs) remain an important problem in the pediatric population, despite the efforts made to reduce their incidence,<a class="elsevierStyleCrossRefs" href="#bib0005">1–5</a> which in the developed countries has been estimated to be about 75–125 cases/100,000 children/year. Of these cases, approximately 7–10% are regarded as serious.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6</a>In comparison with the general population,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> pediatric patients suffer a greater frequency of intracranial injuries, with a different response to injury and a better prognosis for one same degree of brain damage, as a result of anatomical and physiopathological factors.<a class="elsevierStyleCrossRef" href="#bib0040">8</a>In pediatric patients, where brain maturation is in full process, it is essential to avoid secondary lesions which in association with the initial primary injury characterizing all HIs, can increase morbidity–mortality by up to 30–40%.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6,9</a>Our more than 25 years of experience as a provincial reference center in the management of children with serious head injuries (SHIs) has allowed us to conduct the present study.The objectives of the study have been: (a) to describe the main epidemiological, clinical and evolutive characteristics of pediatric patients with SHIs; and (b) to analyze their differences in different periods of the study and in different age groups.Material and methodStudy: retrospective (August 1983–December 1998), prospective (January 1999–December 2009).Setting: (a) reference population: children aged between 1 month and 14 years, with HIs, exhibiting a Glasgow Coma Scale (GCS) score of ≤8; (b) hospital center: third-level hospital serving as provincial reference center (The Canary Islands (Spain): Gran Canaria, Fuerteventura and Lanzarote), serving a pediatric population of 137,538 children.Study variables<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Quantitative variables: age, GCS score, pediatric risk of mortality score (PRISM), duration of mechanical ventilation, stay in ICU, Glasgow Outcome Scale (GOS).</li><li class="elsevierStyleListItem" id="lsti0010">2.Qualitative variables: gender, origin, mortality, cause of HI, associated extracranial injuries, lesions on cranial CT scan, sequelae, presence of hyperglycemia, anemia, shock or pupil mydriasis, need for monitoring of intracranial pressure (ICP) and jugular venous oxygen saturation (SjO2), existence of intracranial hypertension (ICH), and need for mechanical ventilation.</li></ul>Criteria employed<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">1.GCS: following patient stabilization we used the first reflected value of the classical Glasgow scale<a class="elsevierStyleCrossRef" href="#bib0050">10</a> or its modification for pediatric patients.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> The latter is distinguished from the classical scale only in terms of the verbal response section, which is scored as follows: babbling (5), irritable crying (4), crying in response to pain (3), complaint or sighing in response to pain (2), no response (1).</li><li class="elsevierStyleListItem" id="lsti0020">2.SHI: GCS score ≤8.</li><li class="elsevierStyleListItem" id="lsti0025">3.PRISM score: pediatric risk of mortality score.<a class="elsevierStyleCrossRef" href="#bib0060">12</a></li><li class="elsevierStyleListItem" id="lsti0030">4.Polytraumatized patient<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a>: serious injuries affecting at least two body regions (skull/brain, thorax, abdomen, musculoskeletal system), or three major fractures. Serious injury is that affecting: (a) skull: unconsciousness or neurological focality, bleeding from nose, bleeding from ears, or facial fracture; (b) thorax: rib fractures, sternal fracture, pneumothorax, hemothorax, lung contusion, aortic rupture, cardiac tamponade or ruptured diaphragm; (c) abdomen: organ laceration or contusion; and (d) musculoskeletal system: vertebral body or arch fracture, fracture of the pelvis, femur, tibia, humerus, or amputation of extremities.</li><li class="elsevierStyleListItem" id="lsti0035">5.Lesion evidenced by CT: we used the classification of the Trauma Coma Data Bank (TCDB),<a class="elsevierStyleCrossRef" href="#bib0075">15</a> which is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Severe diffuse brain injury (SDBI) was taken to represent diffuse brain injury (DBI) III and DBI IV.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040">6.Shock: existence of systolic blood pressure <55mmHg in patients under 1 year of age and <65mmHg in those over 1 year, with organ repercussions and the need for fluid therapy (≥20ml/kg) and/or catecholamines for control.<a class="elsevierStyleCrossRef" href="#bib0060">12</a></li><li class="elsevierStyleListItem" id="lsti0045">7.Hyperglycemia: blood glucose >200mg/dl.</li><li class="elsevierStyleListItem" id="lsti0050">8.Mechanical ventilation: patients requiring ventilation with intermittent positive pressure at the time of HI or in relation to the latter.</li><li class="elsevierStyleListItem" id="lsti0055">9.Anemia: hemoglobin <8g% or the need for transfusion of red cell concentrates ≥10ml/kg.</li><li class="elsevierStyleListItem" id="lsti0060">10.Monitoring of ICP: performed with different pressure systems and in different locations according to the clinical case or technical availability.</li><li class="elsevierStyleListItem" id="lsti0065">11.ICH: ICP >20mmHg on a sustained basis despite control of all the intracranial or extracranial factors capable of influencing its measurement.</li><li class="elsevierStyleListItem" id="lsti0070">12.Mydriasis: non-reactive unilateral or bilateral dilatation of the pupil >4mm.</li><li class="elsevierStyleListItem" id="lsti0075">13.SjO2: monitoring after retrograde internal jugular vein catheterization, with radiological verification of the location in the jugular bulbar zone. The determinations were performed on an intermittent basis.</li><li class="elsevierStyleListItem" id="lsti0080">14.Arterio-jugular oxygen difference (Sa-jO2)<a class="elsevierStyleCrossRef" href="#bib0080">16</a>: difference between SaO2 and SjO2. Three possibilities were considered: (a) brain hyperemia: Sa-jO2<20%; (b) brain ischemia: Sa-jO2>40%; and (c) normal: Sa-jO2 between 20 and 40%.</li><li class="elsevierStyleListItem" id="lsti0085">15.Clinical outcome: at discharge from the PICU, the patients were classified into four categories according to the Glasgow Outcome Scale (GOS)<a class="elsevierStyleCrossRef" href="#bib0085">17</a>: (a) death; (b) vegetative state: unable to reciprocally interact with the environment, or severe disability: able to follow instructions, unable to live independently; (c) moderate disability: able to live independently; and (d) good recovery: able to return to baseline situation before HI.</li><li class="elsevierStyleListItem" id="lsti0090">16.Age groups: the population was classified into three groups: under 2 years, between 2 and 6 years, and over 6 years.</li><li class="elsevierStyleListItem" id="lsti0095">17.Periods of study: (a) first 15 years (1983–1998); and (b) last decade (1999–2009).</li></ul>Statistical analysisThe data obtained were processed with the Statistical Package for Social Sciences (SPSS) version 17.0. The Student's t-test was used for the comparison of means, while the chi-squared test or Fisher exact test was used for the comparison of percentages. The level of significance was established for alpha=0.05.ResultsDuring the period of the study, 389 children were admitted to the PICU due to HI, this representing an incidence of 11 cases/100,000 children/year. Of these cases, 174 (45%) presented GCS≤8, and these were the patients included in the study, as they were taken to represent cases of SHI. Thus, the incidence of pediatric SHI was 5 cases/100,000 children/year. Males predominated (67%), and the mean patient age was 67.96±41.6 months, with a range of 1–166 months (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). A total of 106 patients (61%) were admitted to the PICU from the emergency area, while 66 patients (38%) had been transferred from other hospitals.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The causes of SHI are reported in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, with a predominance of traffic accidents (56%), followed by falls from a height (24%).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Fifty-five percent of the study population suffered cranial fracture, and 58 patients (33%) presented other associated extracranial traumatisms. In turn, 66% of the children presented anemia, with an association of hyperglycemia or shock in 38% and 37% of the cases, respectively. Mechanical ventilation was provided in 92.5% of the patients.Regarding the most relevant neurological variables, the mean GCS was 5.55±1.8; <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the percentage distribution. Thirty-five percent of the patients presented pupil mydriasis. ICP was monitored in 104 children (60%); 79% presented ICH. The jugular bulb was catheterized in 25% of the children with ICH; the determinations made revealed Sa-jO2 values compatible with brain hyperemia in 70% of the cases, with brain ischemia in 20%. The values proved normal in 10% of the cases.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Regarding the lesions evidenced by CT, it should be noted that in 55% of the cases of diffuse brain injury, the latter proved severe (SDBI).The mean stay in the ICU was 9.1±13 days, with a median of 5 days, whereas the mean duration of mechanical ventilation was 99.41±58h, with a median of 48h. The mean PRISM score was 10.77±6.7.The modified Glasgow Outcome Scale (GOS) score at discharge from the PICU was: (a) 43 patients (24.7%) died; (b) 38 patients (22%) were in a vegetative condition or presented severe disability; (c) 21 patients (12.3%) suffered moderate disability; and (d) 71 patients (41%) showed good recovery.We analyzed some of the above commented aspects in relation to the three age groups into which the study population was divided. In children under 2 years of age, HIs were mainly caused by accidental falls (33%) and falls from heights (33%). Of note is the observation that aggressions or abuse were the cause of injury in 13% of the cases. After 2 years of age, in both the 2–6 years and over 6 years age groups, traffic accidents were the main cause of HIs (57.1% and 68.9%, respectively).Cranial fractures were uniformly distributed in all three groups, in the same way as shock, anemia, hyperglycemia and ICH.SDBI as evidenced by CT was seen to increase in frequency with age: 26.7% in those under 2 years of age, 34.7% in those aged 2–6 years, and 48.6% in those over 6 years of age. These differences came close to statistical significance (p=0.06).The mortality rates in the three groups showed no significant differences (26.7%, 31.4% and 17.6%, respectively), though on comparing the patients under 6 years of age with those over 6 years, greater mortality was observed in the former (30%) versus the latter (17.6%) – the difference being almost significant (p=0.06).A comparison was made of the two study periods (first 15 years versus the last decade), revealing the following differences:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0100">1.Traffic accidents as a cause of SHI in pediatric patients decreased significantly (58.5% vs 45.3%; p<0.001).</li><li class="elsevierStyleListItem" id="lsti0105">2.SDBI as evidenced by CT (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) presented a significantly higher incidence in the first period versus the second (44.5% vs 24.5%; p<0.05).<elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0110">3.There were no significant differences between the two groups in terms of the monitoring of ICP (58.6% vs 63.8%; NS).</li><li class="elsevierStyleListItem" id="lsti0115">4.There was a higher incidence of ICH in the children with HI in the first 15 years of the study versus the last 10 years (88% vs 54%; p<0.05).</li><li class="elsevierStyleListItem" id="lsti0120">5.Mortality decreased from 25.5% to 15.1% in the last decade—the difference between the two periods being nonsignificant.</li><li class="elsevierStyleListItem" id="lsti0125">6.Clinical outcome in the form of adequate recovery as established from the modified GOS (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) was significantly more common in the last decade (23.3% vs 63.1%; p<0.001).<elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul>DiscussionIn our study population, SHIs represented almost one-half of all HIs treated in the PICU, the incidence of pediatric SHIs being 5 cases/100,000 children/year—this figure being slightly lower than reported in other series, with incidences of between 7 and 12 cases/100,000 children/year.<a class="elsevierStyleCrossRefs" href="#bib0005">1,6</a> However, in the group of patients with SHI, 47% presented a GCS score of under 6.The mean age in our series (5.6 years) was slightly lower than in current series which report ages of between 7 and 8 years.<a class="elsevierStyleCrossRefs" href="#bib0090">18–21</a> We found no differences in mortality between the three age groups studied, in coincidence with the observations of White et al.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> However, in most studies, mortality is greater in younger children, particularly among those under 6 years of age<a class="elsevierStyleCrossRefs" href="#bib0020">4,23–25</a>; in our population the differences came close to statistical significance (30% for those under 6 years versus 17.6% among those over 6 years; p=0.06).The most common cause of SHI in pediatric patients was traffic accidents, in coincidence with the reports of other authors.<a class="elsevierStyleCrossRefs" href="#bib0105">21,25</a> Of note was the observation that all recorded cases of aggression or abuse (2.3%) corresponded to the group of infants under two years of age; this fact should be taken into account in situations of neurological damage of indeterminate cause in this group of patients.As commented above, practically one-half of all the pediatric patients with HIs in our series presented GCS<6, i.e., these corresponded to cases of SHI. Another finding was the existence of pupil mydriasis in one-third of the population, which coincides with the incidence recently reported by Bahlout et al.,<a class="elsevierStyleCrossRef" href="#bib0005">1</a> and which together with the GCS score reflects the severity of the cases analyzed. In this same line, practically 80% of our patients subjected to ICP monitorization presented ICH. We therefore consider ICP monitoring to be a priority in children with SHIs.<a class="elsevierStyleCrossRef" href="#bib0130">26</a>A significant observation was that 25% of the patients with ICH were subjected to SjO2 monitorization; this is relevant in view of the limited data available on this point in the literature related to pediatric patients. Although starting in the year 1993 a progressive increase in SjO2 monitoring was recorded among the patients with persistent ICH, this technique has not been standardized—possibly because of problems of interpretation, since it constitutes a local measure of cerebral blood flow and oxygen consumption (VOc) and of their adequate correlation in concrete clinical situations (brain death, barbiturate coma, etc.). Likewise, continuous monitorization systems tend to present the inconvenience of requiring frequent calibrations. Nevertheless, in our series the predominant pattern corresponded to brain hyperemia, coinciding with the clinical and radiological findings in pediatric SHI, characterized by an increase in cerebral blood flow and of the risk of brain edema.<a class="elsevierStyleCrossRefs" href="#bib0135">27–29</a>In our study, the incidence of brain edema regarded as SDBI (grades III and IV according to the criteria of the TCDB<a class="elsevierStyleCrossRef" href="#bib0075">15</a>) was approximately 40%, and very similar to the figures published by Esparza et al.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> and Bahlout et al.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> On analyzing the CT lesions in the different age groups, we noted a lesser incidence of SDBI among the younger patients. This could be explained by anatomical factors such as the persistence of open sutures, conferring greater skull and brain elasticity and plasticity in these early ages.Other extracerebral factors such as anemia, the existence of shock or hyperglycemia, were found to be more frequent than in other studies.<a class="elsevierStyleCrossRefs" href="#bib0005">1,3</a>The mean PRISM score in our patients was 10.6, which is intermediate in comparison with the values recorded for other critical patients (sepsis, cardiogenic shock, severe respiratory failure, etc.). This could be explained by considering that in only 33% of the cases was SHI associated to polytraumatism, as a result of which the fundamental PRISM score is derived from the GCS score—since normally and apart from the neurological impairment, those patients with SHI who do not die present only minimal organ dysfunction (PRISM 8.9±5 vs 22.2±5.3; p<0.001).As regards the clinical course and prognosis, we must underscore the important morbidity (34%) and mortality (25%) among the children with SHI as evidenced by the modified GOS at discharge from the PICU. In general, many children, once moved to the ward and subjected to standardization of the rehabilitation-physiotherapy measures, with an increased contact with close relatives, experience improvement of their initial sequelae.The time course of the studied variables shows a tendency towards fewer traffic accidents as a cause of SHIs in pediatric patients, with a reduction in mortality (which although not statistically significant does seem evident, from 25.5% to 15.1%), and greater clinical recovery during the last decade.Although the monitoring of ICP showed no significant differences, there was a greater incidence of ICH in the first period studied, and the severity of diffuse brain damage as evidenced by CT was also greater.These differences observed in the children with SHI (fundamentally lesser severity and improved recovery) in the course of the 25 years of the study can be explained by improved care—though other contributing factors must also be taken into account: improvements in traffic safety, retention systems and devices in vehicles, prompt patient treatment and out-hospital resuscitation, etc.This study thus focuses on the epidemiological, clinical and evolutive aspects that confirm the data reported by the few published series, and moreover also contributes new aspects that have been very little explored in the literature on serious head injuries.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres9150" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Material and method" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec10590" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres9151" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y método" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec10591" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Study variables" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Criteria employed" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2010-09-21" "fechaAceptado" => "2011-02-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec10590" "palabras" => array:4 [ 0 => "Pediatric head injury" 1 => "Epidemiology" 2 => "Clinical manifestations" 3 => "Evolution" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec10591" "palabras" => array:4 [ 0 => "Traumatismo craneoencefálico pediátrico" 1 => "Epidemiología" 2 => "Clínica" 3 => "Evolución" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo describe the epidemiology, clinical manifestations and evolutive characteristics of pediatric patients with severe head injury (SHI). Material and methodA review was made of the patients admitted to the pediatric intensive care unit (PICU) with SHI between July 1983 and December 2009. ResultsOf the 389 patients with head injuries admitted to the PICU during the study period, 174 (45%) presented SHI. The mean age in this group was of 67±9 months, with a Glasgow Coma Score (GCS) of 5.5±1.8 and a PRISM score of 10.7±6.7. The most frequent etiology of SHI was traffic accidents (56%), though these have decreased significantly in the last decade (58.5% vs 45.3%; p<0.001). Twenty-one percent of the patients required evacuation of the lesions detected by computed tomography (CT), and 39% presented severe diffuse encephalic injury (DEI). Seventy-nine percent of the patients in whom intracranial pressure (ICP) was monitored presented intracranial hypertension. Sequelae of clinical relevance were recorded in 59 patients (39%), and proved serious in 64% of the cases. The mortality rate in this patient series was 24.7%. Intracranial hypertension decreased significantly in the last decade (88% vs 54%; p<0.05), and clinical recovery has improved (23.3% vs 63.1%; p<0.001). Conclusions(a) The incidence of traffic accidents has decreased in the last decade in the studied population; (b) patients with SHI in which ICP was monitored showed a high incidence of intracranial hypertension; (c) morbidity–mortality among pediatric patients with SHI has decreased over the course of the study period." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "ObjetivoDescribir las características epidemiológicas, clínicas y evolutivas de los pacientes pediátricos con traumatismo craneoencefálico grave (TCEG). Material y métodoRevisión de los pacientes ingresados en una unidad de medicina intensiva pediátrica (UMIP) con TCEG en el periodo comprendido entre julio de 1983 y diciembre de 2009. ResultadosDe los 389 pacientes con traumatismo craneoencefálico (TCE) ingresados en nuestra unidad durante el periodo de estudio, presentaron TCEG 174 (45%). La media de edad de este grupo fue 67±9meses, con una puntuación media en la escala de Glasgow (GCS) de 5,5±1,8 y una puntuación PRISM media de 10,7±6,7. La etiología más frecuente de los TCEG fueron los accidentes de tráfico (56%), aunque en la última década existe una disminución significativa de su incidencia (el 58,5 frente al 45,3%; p<0,001). Un 21% de los pacientes precisaron evacuación de la lesión objetivada en la TC, objetivándose en un 39% lesión encefálica difusa (LED) grave. Un 79% de los pacientes en los que se monitorizó la presión intracraneal (PIC) presentaron hipertensión intracraneal (HTC). Las secuelas de relevancia clínica se objetivaron en 59pacientes (39%), siendo graves en el 64% de ellos. La mortalidad de la población estudiada fue de un 24,7%. La incidencia de HTC fue significativamente menor en la última década estudiada (el 88 frente al 54%; p<0,05), con una mejor recuperación clínica (el 23,3 frente al 63,1%; p<0,001). Conclusionesa) La incidencia de los accidentes de tráfico disminuyó en la última década en la población estudiada; b) los pacientes con TCEG en los que se monitorizó la PIC presentaron una alta incidencia de HTC, y c) la morbimortalidad de los TCEG pediátricos disminuyó a lo largo del periodo de estudio." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: López Álvarez JM, et al. Traumatismo craneoencefálico pediátrico grave (I). Epidemiología, clínica y evolución. Med Intensiva. 2011;35:331–6." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 896 "Ancho" => 1667 "Tamanyo" => 64804 ] ] "descripcion" => array:1 [ "en" => "Etiology of pediatric SHIs." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 944 "Ancho" => 1597 "Tamanyo" => 59102 ] ] "descripcion" => array:1 [ "en" => "Percentage distribution of the GCS score in the pediatric patients with SHIs." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 861 "Ancho" => 1583 "Tamanyo" => 78512 ] ] "descripcion" => array:1 [ "en" => "Percentage distribution of the CT findings in the two compared study periods." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 750 "Ancho" => 1597 "Tamanyo" => 65802 ] ] "descripcion" => array:1 [ "en" => "Percentage distribution of the modified GOS scores in the two compared study periods." ] ] 4 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "TCDB, Trauma Coma Data Bank; Cranial volume, under 2 years, 85% of the adult volume; over 8 years, same as in the adult." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Category \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Definition \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type I diffuse brain injury (DBI I) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal CT \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type II diffuse brain injury (DBI II) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Small focal lesion (<25ml). May include bone fragments or others. Midline displacement <5mm. Cisterns present \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type III diffuse brain injury (DBI III) or swelling \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obliteration of basal cisterns. Small focal lesion (<25ml). Midline displacement <5mm \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type IV diffuse brain injury (DBI IV) or shift \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Midline displacement >5mm. Small focal lesion (<25ml) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type V evacuated brain injury (EBI V) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass evacuated through surgery \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type VI non-evacuated brain injury (NEBI VI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mass not evacuated >25ml \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab8741.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Classification of the brain injuries according to the CT findings (TCDB criteria<a class="elsevierStyleCrossRef" href="#bib0075">15</a>)." ] ] 5 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Data expressed as mean±standard deviation [median] or n (%)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.9±41.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Males \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">117 (67.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Females \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">57 (32.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PRISM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10.77±6.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GCS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.5±1.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stay in PICU (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.1±13 [5] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Duration of mechanical ventilation (h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99.4±58 [48] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (24.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab8740.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Demographic and clinical variables of the study population." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe head injury among children: prognostic factors and outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Bahloul" 1 => "B.H. Chokri" 2 => "C. Hedi" 3 => "C. Adel" 4 => "K. Harem" 5 => "D. Hassen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.injury.2008.04.018" "Revista" => array:6 [ "tituloSerie" => "Injury" "fecha" => "2009" "volumen" => "40" "paginaInicial" => "535" "paginaFinal" => "540" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18703191" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors of acute child and family outcome following traumatic brain injury in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V.A. Anderson" 1 => "C. Catroppa" 2 => "F. Haritou" 3 => "S. Morse" 4 => "L. Pentlnad" 5 => "J. Rosenfeld" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "56009" "Revista" => array:6 [ "tituloSerie" => "Pediatr Neurosurg" "fecha" => "2001" "volumen" => "34" "paginaInicial" => "138" "paginaFinal" => "148" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11359102" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome after mild-to-moderate blunt head injury: effects of focal lesions and diffuse axonal injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.W. Wallesch" 1 => "N. Curio" 2 => "S. Kutz" 3 => "S. Jost" 4 => "C. Bartels" 5 => "H. Synowitz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/02699050010005959" "Revista" => array:6 [ "tituloSerie" => "Brain Injury" "fecha" => "2001" "volumen" => "15" "paginaInicial" => "401" "paginaFinal" => "412" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11350654" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Medical and cognitive outcome in children with traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Campbell" 1 => "S. Kuehn" 2 => "P. Richards" 3 => "E. Ventureyra" 4 => "J. Hutchison" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Can J Neurol Sci" "fecha" => "2004" "volumen" => "31" "paginaInicial" => "213" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15198446" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Health-related quality of life during the first year after traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. McCarthy" 1 => "E. McKenzie" 2 => "D. Durbin" 3 => "M. Aitken" 4 => "K. Jaffe" 5 => "C. Paidas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archpedi.160.3.252" "Revista" => array:6 [ "tituloSerie" => "Arch Pediatr Adolesc Med" "fecha" => "2006" "volumen" => "160" "paginaInicial" => "252" "paginaFinal" => "260" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16520444" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Traumatic brain injury in children" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "C. Giza" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "Pediatric neurology. Principles and practice" "edicion" => "4th ed." "serieFecha" => "2006" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Actualizaciones en el manejo del traumatismo craneoencefálico grave" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E. Alted" 1 => "S. Bermejo" 2 => "M. Chico" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2009" "volumen" => "33" "paginaInicial" => "16" "paginaFinal" => "30" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19232206" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatrics head injury: what is unique and different" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "H.E. James" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Acta Neurochir" "fecha" => "1999" "volumen" => "73" "paginaInicial" => "85" "paginaFinal" => "88" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Disfunción autonómica en el niño con traumatismo craneoencefálico" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "N. Rodriguez" 1 => "A. Febrer" 2 => "M. Meléndez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Neurol" "fecha" => "2006" "volumen" => "43" "paginaInicial" => "143" "paginaFinal" => "146" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16871479" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of coma and impaired consciousness. A practical scale" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "G. Teadsdale" 1 => "B. Jennet" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1974" "volumen" => "2" "paginaInicial" => "81" "paginaFinal" => "84" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2567876" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assesing the conscious level of the Glasgow Coma Scale" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.L. Reilly" 1 => "D.A. Simpson" 2 => "R. Sprod" 3 => "L. Thomas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Child's Nerv Syst" "fecha" => "1988" "volumen" => "4" "paginaInicial" => "30" "paginaFinal" => "33" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric risk of mortality (PRISM) score" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.M. Pollack" 1 => "U.E. Ruttimann" 2 => "P.R. Getson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "1988" "volumen" => "16" "paginaInicial" => "1110" "paginaFinal" => "1116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3048900" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multiple organ failure in polytrauma patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F. Faist" 1 => "A.E. Baue" 2 => "H. Dittmer" 3 => "G. Heberer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "1983" "volumen" => "23" "paginaInicial" => "775" "paginaFinal" => "787" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6620431" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk factors for multiorgan failure. A case control study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "F. Henao" 1 => "J. Daes" 2 => "R. Dennis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Trauma" "fecha" => "1991" "volumen" => "31" "paginaInicial" => "74" "paginaFinal" => "80" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1986136" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The Traumatic Coma Data Bank: design, methods, and baseline characteristics" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M.A. Foulkes" 1 => "H.M. Eisemberg" 2 => "J.A. Jane" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3171/jns.1991.75.1.0008" "Revista" => array:6 [ "tituloSerie" => "J Neurosurg" "fecha" => "1991" "volumen" => "75" "paginaInicial" => "8" "paginaFinal" => "36" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2045924" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury: preliminary observations" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Cruz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit Care Med" "fecha" => "1993" "volumen" => "21" "paginaInicial" => "1225" "paginaFinal" => "1232" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8339591" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Assessment of outcome after severe brain damage" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B. Jennett" 1 => "M. Bond" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1975" "volumen" => "1" "paginaInicial" => "480" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2893908" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. Pillai" 1 => "S.S. Praharaj" 2 => "A. Mohanty" 3 => "V.R. Kolluri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "56002" "Revista" => array:6 [ "tituloSerie" => "Pediatr Neurosurg" "fecha" => "2001" "volumen" => "34" "paginaInicial" => "98" "paginaFinal" => "103" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11287810" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pediatric neurointensive care: 2008 Update for the Rogers’ Textbook of pediatric intensive care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Kochanek" 1 => "R. Tasker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/PCC.0b013e3181ab88cd" "Revista" => array:6 [ "tituloSerie" => "Pediatr Crit Care Med" "fecha" => "2009" "volumen" => "10" "paginaInicial" => "517" "paginaFinal" => "523" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19584637" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.D. Adelson" 1 => "S.L. Bratton" 2 => "N.A. Carney" 3 => "R.M. Chessnut" 4 => "H.E. Du Coudray" 5 => "B. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/01.CCM.0000066600.71233.01" "Revista" => array:6 [ "tituloSerie" => "Pediatr Crit Care Med" "fecha" => "2003" "volumen" => "4" "paginaInicial" => "S2" "paginaFinal" => "S4" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12847337" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Childhood head injury: causes, outcome and outcome predictors" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Odeboe" 1 => "A. Abubakar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00383-004-1196-5" "Revista" => array:6 [ "tituloSerie" => "Pediatr Surg Int" "fecha" => "2004" "volumen" => "20" "paginaInicial" => "348" "paginaFinal" => "352" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15179518" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictors of outcome in severely head-injured children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. White" 1 => "Z. Farukhi" 2 => "C. Bull" 3 => "J. Christensen" 4 => "T. Gordon" 5 => "C. Paidas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Crit care Med" "fecha" => "2001" "volumen" => "29" "paginaInicial" => "534" "paginaFinal" => "540" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11373416" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic factors and outcome of children with severe head injury. An 8-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Chiaretti" 1 => "M. Piastra" 2 => "S. Pulitano" 3 => "D. Pietrini" 4 => "G. De Rosa" 5 => "R. Barbaro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Child's Nerv Syst" "fecha" => "2002" "volumen" => "18" "paginaInicial" => "129" "paginaFinal" => "136" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Longitudinal neuropsychological outcome in infants and preschoolers with traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Edwing" 1 => "J.M. Fletcher" 2 => "H.S. Levin" 3 => "D.J. Francis" 4 => "K. Davidson" 5 => "M.E. Miner" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Int Neuropsychol Soc" "fecha" => "1997" "volumen" => "3" "paginaInicial" => "581" "paginaFinal" => "591" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9448371" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Head injury" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R. Gedeit" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Pediatr Rev" "fecha" => "2001" "volumen" => "22" "paginaInicial" => "118" "paginaFinal" => "124" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11283324" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Chapter 5: Indication for intracranial pressure monitoring in pediatric patient with severe traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.D. Adelson" 1 => "S.L. Bratton" 2 => "N.A. Carney" 3 => "R.M. Chessnut" 4 => "H.E. Du Coudray" 5 => "B. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Crit Care Med" "fecha" => "2003" "volumen" => "4" "paginaInicial" => "S20" "paginaFinal" => "S25" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Traumatismo craneoencefálico grave en el paciente pediátrico. Evaluación de la neuroimagen y monitorización de la presión intracraneal como factores pronóstico" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Fernández" 1 => "A. Palomeque" 2 => "F.J. Cambra" 3 => "J. Ortega" 4 => "J.M. Costa" 5 => "J. Caritg" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Intensiva" "fecha" => "2001" "volumen" => "25" "paginaInicial" => "8" "paginaFinal" => "13" ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Traumatismo craneoencefálico pediátrico grave. Factores predictores de mortalidad" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.M. López" 1 => "J.M. Limiñana" 2 => "A. Jiménez" 3 => "E. Consuegra" 4 => "A. Morón" 5 => "R. González" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Intensiva" "fecha" => "2003" "volumen" => "27" "paginaInicial" => "155" "paginaFinal" => "161" ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0145" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants, children and adolescents. Chapter 17: Critical pathway for the treatment of estabilished intracranial hypertension in pediatric traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.D. Adelson" 1 => "S.L. Bratton" 2 => "N.A. Carney" 3 => "R.M. Chessnut" 4 => "H.E. Du Coudray" 5 => "B. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Pediatr Crit Care Med" "fecha" => "2003" "volumen" => "4" "paginaInicial" => "S66" "paginaFinal" => "S68" ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0150" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Outcome in children with severe head injuries" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Esparza" 1 => "J. Portillo" 2 => "M. Sarabia" 3 => "J. Yuste" 4 => "R. Roger" 5 => "E. Lmas" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Child's Nerv Syst" "fecha" => "1985" "volumen" => "1" "paginaInicial" => "109" "paginaFinal" => "114" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000178/v1_201212101034/en/main.assets" "Apartado" => array:4 [ "identificador" => "404" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Originals" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003500000006/v1_201212101034/S2173572711000178/v1_201212101034/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000178?idApp=WMIE"]

Statistics

Original

Severe pediatric head injuries (I). Epidemiology, clinical manifestations and course

Traumatismo craneoencefálico pediátrico grave (I). Epidemiología, clínica y evolución

J.M. López Álvareza,

Corresponding author

jmloal@hotmail.com

Corresponding author.

, M.E. Valerón Lemaura, O. Pérez Quevedoa, J.M. Limiñana Cañalb, A. Jiménez Bravo de Lagunaa, E. Consuegra Llapurta, A. Morón Saén de Casasa, R. González Jorgea

a Unidad de Medicina Intensiva Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil de Canarias, Las Palmas de Gran Canaria, Spain

b Departamento de Bioestadística, Facultad de Medicina, Las Palmas de Gran Canaria, Spain

Read

1039

Times
was read the article

490

Total PDF

549

Total HTML

Share statistics

 array:23 [
  "pii" => "S2173572711000178"
  "issn" => "21735727"
  "doi" => "10.1016/j.medine.2011.02.002"
  "estado" => "S300"
  "fechaPublicacion" => "2011-08-01"
  "aid" => "265"
  "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
  "copyrightAnyo" => "2010"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Med Intensiva. 2011;35:331-6"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 2014
    "formatos" => array:3 [
      "EPUB" => 129
      "HTML" => 1319
      "PDF" => 566
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S2173572711000208"
    "issn" => "21735727"
    "doi" => "10.1016/j.medine.2011.02.005"
    "estado" => "S300"
    "fechaPublicacion" => "2011-08-01"
    "aid" => "270"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Med Intensiva. 2011;35:337-43"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2825
      "formatos" => array:3 [
        "EPUB" => 141
        "HTML" => 1390
        "PDF" => 1294
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original</span>"
      "titulo" => "Serious pediatric head injuries &#40;II&#41;&#58; factors associated to morbidity&#8211;mortality"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "337"
          "paginaFinal" => "343"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Traumatismo craneoencef&#225;lico pedi&#225;trico grave &#40;II&#41;&#58; factores relacionados con la morbilidad y mortalidad"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Figure 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 806
              "Ancho" => 1611
              "Tamanyo" => 80483
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of the incidence and mortality of pediatric serious head injuries in the different periods of the study&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "J&#46;M&#46; L&#243;pez &#193;lvarez, M&#46;E&#46; Valer&#243;n Lemaur, O&#46; P&#233;rez Quevedo, J&#46;M&#46; Limi&#241;ana Ca&#241;al, A&#46; Jim&#233;nez Bravo de Laguna, E&#46; Consuegra Llapurt, A&#46; Mor&#243;n Sa&#233;n de Casas, R&#46; Gonz&#225;lez Jorge"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "J&#46;M&#46;"
              "apellidos" => "L&#243;pez &#193;lvarez"
            ]
            1 => array:2 [
              "nombre" => "M&#46;E&#46;"
              "apellidos" => "Valer&#243;n Lemaur"
            ]
            2 => array:2 [
              "nombre" => "O&#46;"
              "apellidos" => "P&#233;rez Quevedo"
            ]
            3 => array:2 [
              "nombre" => "J&#46;M&#46;"
              "apellidos" => "Limi&#241;ana Ca&#241;al"
            ]
            4 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Jim&#233;nez Bravo de Laguna"
            ]
            5 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Consuegra Llapurt"
            ]
            6 => array:2 [
              "nombre" => "A&#46;"
              "apellidos" => "Mor&#243;n Sa&#233;n de Casas"
            ]
            7 => array:2 [
              "nombre" => "R&#46;"
              "apellidos" => "Gonz&#225;lez Jorge"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000208?idApp=WMIE"
    "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000208/v1_201212101034/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S2173572711000233"
    "issn" => "21735727"
    "doi" => "10.1016/j.medine.2011.05.001"
    "estado" => "S300"
    "fechaPublicacion" => "2011-08-01"
    "aid" => "301"
    "copyright" => "Elsevier Espa&#241;a&#44; S&#46;L&#46; and SEMICYUC"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "sco"
    "cita" => "Med Intensiva. 2011;35:328-30"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 2650
      "formatos" => array:3 [
        "EPUB" => 156
        "HTML" => 1835
        "PDF" => 659
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>"
      "titulo" => "Towards the future in pediatric intensive care"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "328"
          "paginaFinal" => "330"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Hacia el futuro en cuidados intensivos pedi&#225;tricos"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "E&#46; Ocete Hita"
          "autores" => array:1 [
            0 => array:2 [
              "nombre" => "E&#46;"
              "apellidos" => "Ocete Hita"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000233?idApp=WMIE"
    "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000233/v1_201212101034/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original</span>"
    "titulo" => "Severe pediatric head injuries &#40;I&#41;&#46; Epidemiology&#44; clinical manifestations and course"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "331"
        "paginaFinal" => "336"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "J&#46;M&#46; L&#243;pez &#193;lvarez, M&#46;E&#46; Valer&#243;n Lemaur, O&#46; P&#233;rez Quevedo, J&#46;M&#46; Limi&#241;ana Ca&#241;al, A&#46; Jim&#233;nez Bravo de Laguna, E&#46; Consuegra Llapurt, A&#46; Mor&#243;n Sa&#233;n de Casas, R&#46; Gonz&#225;lez Jorge"
        "autores" => array:8 [
          0 => array:4 [
            "nombre" => "J&#46;M&#46;"
            "apellidos" => "L&#243;pez &#193;lvarez"
            "email" => array:1 [
              0 => "jmloal&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "M&#46;E&#46;"
            "apellidos" => "Valer&#243;n Lemaur"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "O&#46;"
            "apellidos" => "P&#233;rez Quevedo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "J&#46;M&#46;"
            "apellidos" => "Limi&#241;ana Ca&#241;al"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Jim&#233;nez Bravo de Laguna"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "E&#46;"
            "apellidos" => "Consuegra Llapurt"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "A&#46;"
            "apellidos" => "Mor&#243;n Sa&#233;n de Casas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "R&#46;"
            "apellidos" => "Gonz&#225;lez Jorge"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Unidad de Medicina Intensiva Pedi&#225;trica&#44; Complejo Hospitalario Universitario Insular Materno-Infantil de Canarias&#44; Las Palmas de Gran Canaria&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Departamento de Bioestad&#237;stica&#44; Facultad de Medicina&#44; Las Palmas de Gran Canaria&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff0010"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Traumatismo craneoencef&#225;lico pedi&#225;trico grave &#40;I&#41;&#46; Epidemiolog&#237;a&#44; cl&#237;nica y evoluci&#243;n"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 944
            "Ancho" => 1597
            "Tamanyo" => 59102
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of the GCS score in the pediatric patients with SHIs&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Head injuries &#40;HIs&#41; remain an important problem in the pediatric population&#44; despite the efforts made to reduce their incidence&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;5</span></a> which in the developed countries has been estimated to be about 75&#8211;125 cases&#47;100&#44;000 children&#47;year&#46; Of these cases&#44; approximately 7&#8211;10&#37; are regarded as serious&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In comparison with the general population&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> pediatric patients suffer a greater frequency of intracranial injuries&#44; with a different response to injury and a better prognosis for one same degree of brain damage&#44; as a result of anatomical and physiopathological factors&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In pediatric patients&#44; where brain maturation is in full process&#44; it is essential to avoid secondary lesions which in association with the initial primary injury characterizing all HIs&#44; can increase morbidity&#8211;mortality by up to 30&#8211;40&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6&#44;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Our more than 25 years of experience as a provincial reference center in the management of children with serious head injuries &#40;SHIs&#41; has allowed us to conduct the present study&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The objectives of the study have been&#58; &#40;a&#41; to describe the main epidemiological&#44; clinical and evolutive characteristics of pediatric patients with SHIs&#59; and &#40;b&#41; to analyze their differences in different periods of the study and in different age groups&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and method</span><p id="par0030" class="elsevierStylePara elsevierViewall">Study&#58; retrospective &#40;August 1983&#8211;December 1998&#41;&#44; prospective &#40;January 1999&#8211;December 2009&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Setting&#58; &#40;a&#41; reference population&#58; children aged between 1 month and 14 years&#44; with HIs&#44; exhibiting a Glasgow Coma Scale &#40;GCS&#41; score of &#8804;8&#59; &#40;b&#41; hospital center&#58; third-level hospital serving as provincial reference center &#40;The Canary Islands &#40;Spain&#41;&#58; Gran Canaria&#44; Fuerteventura and Lanzarote&#41;&#44; serving a pediatric population of 137&#44;538 children&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study variables</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Quantitative variables&#58; age&#44; GCS score&#44; pediatric risk of mortality score &#40;PRISM&#41;&#44; duration of mechanical ventilation&#44; stay in ICU&#44; Glasgow Outcome Scale &#40;GOS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Qualitative variables&#58; gender&#44; origin&#44; mortality&#44; cause of HI&#44; associated extracranial injuries&#44; lesions on cranial CT scan&#44; sequelae&#44; presence of hyperglycemia&#44; anemia&#44; shock or pupil mydriasis&#44; need for monitoring of intracranial pressure &#40;ICP&#41; and jugular venous oxygen saturation &#40;SjO<span class="elsevierStyleInf">2</span>&#41;&#44; existence of intracranial hypertension &#40;ICH&#41;&#44; and need for mechanical ventilation&#46;</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Criteria employed</span><p id="par0055" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">GCS&#58; following patient stabilization we used the first reflected value of the classical Glasgow scale<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> or its modification for pediatric patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The latter is distinguished from the classical scale only in terms of the verbal response section&#44; which is scored as follows&#58; babbling &#40;5&#41;&#44; irritable crying &#40;4&#41;&#44; crying in response to pain &#40;3&#41;&#44; complaint or sighing in response to pain &#40;2&#41;&#44; no response &#40;1&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2&#46;</span><p id="par0065" class="elsevierStylePara elsevierViewall">SHI&#58; GCS score &#8804;8&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3&#46;</span><p id="par0070" class="elsevierStylePara elsevierViewall">PRISM score&#58; pediatric risk of mortality score&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4&#46;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Polytraumatized patient<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a>&#58; serious injuries affecting at least two body regions &#40;skull&#47;brain&#44; thorax&#44; abdomen&#44; musculoskeletal system&#41;&#44; or three major fractures&#46; Serious injury is that affecting&#58; &#40;a&#41; skull&#58; unconsciousness or neurological focality&#44; bleeding from nose&#44; bleeding from ears&#44; or facial fracture&#59; &#40;b&#41; thorax&#58; rib fractures&#44; sternal fracture&#44; pneumothorax&#44; hemothorax&#44; lung contusion&#44; aortic rupture&#44; cardiac tamponade or ruptured diaphragm&#59; &#40;c&#41; abdomen&#58; organ laceration or contusion&#59; and &#40;d&#41; musculoskeletal system&#58; vertebral body or arch fracture&#44; fracture of the pelvis&#44; femur&#44; tibia&#44; humerus&#44; or amputation of extremities&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">5&#46;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Lesion evidenced by CT&#58; we used the classification of the Trauma Coma Data Bank &#40;TCDB&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> which is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Severe diffuse brain injury &#40;SDBI&#41; was taken to represent diffuse brain injury &#40;DBI&#41; III and DBI IV&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">6&#46;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Shock&#58; existence of systolic blood pressure &#60;55<span class="elsevierStyleHsp" style=""></span>mmHg in patients under 1 year of age and &#60;65<span class="elsevierStyleHsp" style=""></span>mmHg in those over 1 year&#44; with organ repercussions and the need for fluid therapy &#40;&#8805;20<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#41; and&#47;or catecholamines for control&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">7&#46;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Hyperglycemia&#58; blood glucose &#62;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">8&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Mechanical ventilation&#58; patients requiring ventilation with intermittent positive pressure at the time of HI or in relation to the latter&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">9&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Anemia&#58; hemoglobin &#60;8<span class="elsevierStyleHsp" style=""></span>g&#37; or the need for transfusion of red cell concentrates &#8805;10<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">10&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Monitoring of ICP&#58; performed with different pressure systems and in different locations according to the clinical case or technical availability&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">11&#46;</span><p id="par0110" class="elsevierStylePara elsevierViewall">ICH&#58; ICP &#62;20<span class="elsevierStyleHsp" style=""></span>mmHg on a sustained basis despite control of all the intracranial or extracranial factors capable of influencing its measurement&#46;</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">12&#46;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Mydriasis&#58; non-reactive unilateral or bilateral dilatation of the pupil &#62;4<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">13&#46;</span><p id="par0120" class="elsevierStylePara elsevierViewall">SjO<span class="elsevierStyleInf">2</span>&#58; monitoring after retrograde internal jugular vein catheterization&#44; with radiological verification of the location in the jugular bulbar zone&#46; The determinations were performed on an intermittent basis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">14&#46;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Arterio-jugular oxygen difference &#40;Sa-jO<span class="elsevierStyleInf">2</span>&#41;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#58; difference between SaO<span class="elsevierStyleInf">2</span> and SjO<span class="elsevierStyleInf">2</span>&#46; Three possibilities were considered&#58; &#40;a&#41; brain hyperemia&#58; Sa-jO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>20&#37;&#59; &#40;b&#41; brain ischemia&#58; Sa-jO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>40&#37;&#59; and &#40;c&#41; normal&#58; Sa-jO<span class="elsevierStyleInf">2</span> between 20 and 40&#37;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">15&#46;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Clinical outcome&#58; at discharge from the PICU&#44; the patients were classified into four categories according to the Glasgow Outcome Scale &#40;GOS&#41;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#58; &#40;a&#41; death&#59; &#40;b&#41; vegetative state&#58; unable to reciprocally interact with the environment&#44; or severe disability&#58; able to follow instructions&#44; unable to live independently&#59; &#40;c&#41; moderate disability&#58; able to live independently&#59; and &#40;d&#41; good recovery&#58; able to return to baseline situation before HI&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">16&#46;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Age groups&#58; the population was classified into three groups&#58; under 2 years&#44; between 2 and 6 years&#44; and over 6 years&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">17&#46;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Periods of study&#58; &#40;a&#41; first 15 years &#40;1983&#8211;1998&#41;&#59; and &#40;b&#41; last decade &#40;1999&#8211;2009&#41;&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">The data obtained were processed with the Statistical Package for Social Sciences &#40;SPSS&#41; version 17&#46;0&#46; The Student&#39;s <span class="elsevierStyleItalic">t</span>-test was used for the comparison of means&#44; while the chi-squared test or Fisher exact test was used for the comparison of percentages&#46; The level of significance was established for alpha<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">During the period of the study&#44; 389 children were admitted to the PICU due to HI&#44; this representing an incidence of 11 cases&#47;100&#44;000 children&#47;year&#46; Of these cases&#44; 174 &#40;45&#37;&#41; presented GCS<span class="elsevierStyleHsp" style=""></span>&#8804;<span class="elsevierStyleHsp" style=""></span>8&#44; and these were the patients included in the study&#44; as they were taken to represent cases of SHI&#46; Thus&#44; the incidence of pediatric SHI was 5 cases&#47;100&#44;000 children&#47;year&#46; Males predominated &#40;67&#37;&#41;&#44; and the mean patient age was 67&#46;96<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&#46;6 months&#44; with a range of 1&#8211;166 months &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; A total of 106 patients &#40;61&#37;&#41; were admitted to the PICU from the emergency area&#44; while 66 patients &#40;38&#37;&#41; had been transferred from other hospitals&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">The causes of SHI are reported in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; with a predominance of traffic accidents &#40;56&#37;&#41;&#44; followed by falls from a height &#40;24&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Fifty-five percent of the study population suffered cranial fracture&#44; and 58 patients &#40;33&#37;&#41; presented other associated extracranial traumatisms&#46; In turn&#44; 66&#37; of the children presented anemia&#44; with an association of hyperglycemia or shock in 38&#37; and 37&#37; of the cases&#44; respectively&#46; Mechanical ventilation was provided in 92&#46;5&#37; of the patients&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Regarding the most relevant neurological variables&#44; the mean GCS was 5&#46;55<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&#59; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the percentage distribution&#46; Thirty-five percent of the patients presented pupil mydriasis&#46; ICP was monitored in 104 children &#40;60&#37;&#41;&#59; 79&#37; presented ICH&#46; The jugular bulb was catheterized in 25&#37; of the children with ICH&#59; the determinations made revealed Sa-jO<span class="elsevierStyleInf">2</span> values compatible with brain hyperemia in 70&#37; of the cases&#44; with brain ischemia in 20&#37;&#46; The values proved normal in 10&#37; of the cases&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">Regarding the lesions evidenced by CT&#44; it should be noted that in 55&#37; of the cases of diffuse brain injury&#44; the latter proved severe &#40;SDBI&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The mean stay in the ICU was 9&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 days&#44; with a median of 5 days&#44; whereas the mean duration of mechanical ventilation was 99&#46;41<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>58<span class="elsevierStyleHsp" style=""></span>h&#44; with a median of 48<span class="elsevierStyleHsp" style=""></span>h&#46; The mean PRISM score was 10&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;7&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The modified Glasgow Outcome Scale &#40;GOS&#41; score at discharge from the PICU was&#58; &#40;a&#41; 43 patients &#40;24&#46;7&#37;&#41; died&#59; &#40;b&#41; 38 patients &#40;22&#37;&#41; were in a vegetative condition or presented severe disability&#59; &#40;c&#41; 21 patients &#40;12&#46;3&#37;&#41; suffered moderate disability&#59; and &#40;d&#41; 71 patients &#40;41&#37;&#41; showed good recovery&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">We analyzed some of the above commented aspects in relation to the three age groups into which the study population was divided&#46; In children under 2 years of age&#44; HIs were mainly caused by accidental falls &#40;33&#37;&#41; and falls from heights &#40;33&#37;&#41;&#46; Of note is the observation that aggressions or abuse were the cause of injury in 13&#37; of the cases&#46; After 2 years of age&#44; in both the 2&#8211;6 years and over 6 years age groups&#44; traffic accidents were the main cause of HIs &#40;57&#46;1&#37; and 68&#46;9&#37;&#44; respectively&#41;&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Cranial fractures were uniformly distributed in all three groups&#44; in the same way as shock&#44; anemia&#44; hyperglycemia and ICH&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">SDBI as evidenced by CT was seen to increase in frequency with age&#58; 26&#46;7&#37; in those under 2 years of age&#44; 34&#46;7&#37; in those aged 2&#8211;6 years&#44; and 48&#46;6&#37; in those over 6 years of age&#46; These differences came close to statistical significance &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The mortality rates in the three groups showed no significant differences &#40;26&#46;7&#37;&#44; 31&#46;4&#37; and 17&#46;6&#37;&#44; respectively&#41;&#44; though on comparing the patients under 6 years of age with those over 6 years&#44; greater mortality was observed in the former &#40;30&#37;&#41; versus the latter &#40;17&#46;6&#37;&#41; &#8211; the difference being almost significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">A comparison was made of the two study periods &#40;first 15 years versus the last decade&#41;&#44; revealing the following differences&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1&#46;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Traffic accidents as a cause of SHI in pediatric patients decreased significantly &#40;58&#46;5&#37; vs 45&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</span><p id="par0220" class="elsevierStylePara elsevierViewall">SDBI as evidenced by CT &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; presented a significantly higher incidence in the first period versus the second &#40;44&#46;5&#37; vs 24&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3&#46;</span><p id="par0225" class="elsevierStylePara elsevierViewall">There were no significant differences between the two groups in terms of the monitoring of ICP &#40;58&#46;6&#37; vs 63&#46;8&#37;&#59; NS&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">4&#46;</span><p id="par0230" class="elsevierStylePara elsevierViewall">There was a higher incidence of ICH in the children with HI in the first 15 years of the study versus the last 10 years &#40;88&#37; vs 54&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">5&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Mortality decreased from 25&#46;5&#37; to 15&#46;1&#37; in the last decade&#8212;the difference between the two periods being nonsignificant&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">6&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Clinical outcome in the form of adequate recovery as established from the modified GOS &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; was significantly more common in the last decade &#40;23&#46;3&#37; vs 63&#46;1&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></li></ul></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0245" class="elsevierStylePara elsevierViewall">In our study population&#44; SHIs represented almost one-half of all HIs treated in the PICU&#44; the incidence of pediatric SHIs being 5 cases&#47;100&#44;000 children&#47;year&#8212;this figure being slightly lower than reported in other series&#44; with incidences of between 7 and 12 cases&#47;100&#44;000 children&#47;year&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;6</span></a> However&#44; in the group of patients with SHI&#44; 47&#37; presented a GCS score of under 6&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The mean age in our series &#40;5&#46;6 years&#41; was slightly lower than in current series which report ages of between 7 and 8 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;21</span></a> We found no differences in mortality between the three age groups studied&#44; in coincidence with the observations of White et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> However&#44; in most studies&#44; mortality is greater in younger children&#44; particularly among those under 6 years of age<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;23&#8211;25</span></a>&#59; in our population the differences came close to statistical significance &#40;30&#37; for those under 6 years versus 17&#46;6&#37; among those over 6 years&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The most common cause of SHI in pediatric patients was traffic accidents&#44; in coincidence with the reports of other authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;25</span></a> Of note was the observation that all recorded cases of aggression or abuse &#40;2&#46;3&#37;&#41; corresponded to the group of infants under two years of age&#59; this fact should be taken into account in situations of neurological damage of indeterminate cause in this group of patients&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">As commented above&#44; practically one-half of all the pediatric patients with HIs in our series presented GCS<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>6&#44; i&#46;e&#46;&#44; these corresponded to cases of SHI&#46; Another finding was the existence of pupil mydriasis in one-third of the population&#44; which coincides with the incidence recently reported by Bahlout et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and which together with the GCS score reflects the severity of the cases analyzed&#46; In this same line&#44; practically 80&#37; of our patients subjected to ICP monitorization presented ICH&#46; We therefore consider ICP monitoring to be a priority in children with SHIs&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">A significant observation was that 25&#37; of the patients with ICH were subjected to SjO<span class="elsevierStyleInf">2</span> monitorization&#59; this is relevant in view of the limited data available on this point in the literature related to pediatric patients&#46; Although starting in the year 1993 a progressive increase in SjO<span class="elsevierStyleInf">2</span> monitoring was recorded among the patients with persistent ICH&#44; this technique has not been standardized&#8212;possibly because of problems of interpretation&#44; since it constitutes a local measure of cerebral blood flow and oxygen consumption &#40;VOc&#41; and of their adequate correlation in concrete clinical situations &#40;brain death&#44; barbiturate coma&#44; etc&#46;&#41;&#46; Likewise&#44; continuous monitorization systems tend to present the inconvenience of requiring frequent calibrations&#46; Nevertheless&#44; in our series the predominant pattern corresponded to brain hyperemia&#44; coinciding with the clinical and radiological findings in pediatric SHI&#44; characterized by an increase in cerebral blood flow and of the risk of brain edema&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#8211;29</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">In our study&#44; the incidence of brain edema regarded as SDBI &#40;grades III and IV according to the criteria of the TCDB<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41; was approximately 40&#37;&#44; and very similar to the figures published by Esparza et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> and Bahlout et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On analyzing the CT lesions in the different age groups&#44; we noted a lesser incidence of SDBI among the younger patients&#46; This could be explained by anatomical factors such as the persistence of open sutures&#44; conferring greater skull and brain elasticity and plasticity in these early ages&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Other extracerebral factors such as anemia&#44; the existence of shock or hyperglycemia&#44; were found to be more frequent than in other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">The mean PRISM score in our patients was 10&#46;6&#44; which is intermediate in comparison with the values recorded for other critical patients &#40;sepsis&#44; cardiogenic shock&#44; severe respiratory failure&#44; etc&#46;&#41;&#46; This could be explained by considering that in only 33&#37; of the cases was SHI associated to polytraumatism&#44; as a result of which the fundamental PRISM score is derived from the GCS score&#8212;since normally and apart from the neurological impairment&#44; those patients with SHI who do not die present only minimal organ dysfunction &#40;PRISM 8&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5 vs 22&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;3&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">As regards the clinical course and prognosis&#44; we must underscore the important morbidity &#40;34&#37;&#41; and mortality &#40;25&#37;&#41; among the children with SHI as evidenced by the modified GOS at discharge from the PICU&#46; In general&#44; many children&#44; once moved to the ward and subjected to standardization of the rehabilitation-physiotherapy measures&#44; with an increased contact with close relatives&#44; experience improvement of their initial sequelae&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The time course of the studied variables shows a tendency towards fewer traffic accidents as a cause of SHIs in pediatric patients&#44; with a reduction in mortality &#40;which although not statistically significant does seem evident&#44; from 25&#46;5&#37; to 15&#46;1&#37;&#41;&#44; and greater clinical recovery during the last decade&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">Although the monitoring of ICP showed no significant differences&#44; there was a greater incidence of ICH in the first period studied&#44; and the severity of diffuse brain damage as evidenced by CT was also greater&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">These differences observed in the children with SHI &#40;fundamentally lesser severity and improved recovery&#41; in the course of the 25 years of the study can be explained by improved care&#8212;though other contributing factors must also be taken into account&#58; improvements in traffic safety&#44; retention systems and devices in vehicles&#44; prompt patient treatment and out-hospital resuscitation&#44; etc&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">This study thus focuses on the epidemiological&#44; clinical and evolutive aspects that confirm the data reported by the few published series&#44; and moreover also contributes new aspects that have been very little explored in the literature on serious head injuries&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0310" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:13 [
        0 => array:2 [
          "identificador" => "xres9150"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Objective"
            2 => "Material and method"
            3 => "Results"
            4 => "Conclusions"
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec10590"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres9151"
          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivo"
            2 => "Material y m&#233;todo"
            3 => "Resultados"
            4 => "Conclusiones"
          ]
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec10591"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Material and method"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Study variables"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Criteria employed"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Statistical analysis"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Results"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Discussion"
        ]
        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflicts of interest"
        ]
        12 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2010-09-21"
    "fechaAceptado" => "2011-02-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec10590"
          "palabras" => array:4 [
            0 => "Pediatric head injury"
            1 => "Epidemiology"
            2 => "Clinical manifestations"
            3 => "Evolution"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec10591"
          "palabras" => array:4 [
            0 => "Traumatismo craneoencef&#225;lico pedi&#225;trico"
            1 => "Epidemiolog&#237;a"
            2 => "Cl&#237;nica"
            3 => "Evoluci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To describe the epidemiology&#44; clinical manifestations and evolutive characteristics of pediatric patients with severe head injury &#40;SHI&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Material and method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A review was made of the patients admitted to the pediatric intensive care unit &#40;PICU&#41; with SHI between July 1983 and December 2009&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 389 patients with head injuries admitted to the PICU during the study period&#44; 174 &#40;45&#37;&#41; presented SHI&#46; The mean age in this group was of 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9 months&#44; with a Glasgow Coma Score &#40;GCS&#41; of 5&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8 and a PRISM score of 10&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;7&#46; The most frequent etiology of SHI was traffic accidents &#40;56&#37;&#41;&#44; though these have decreased significantly in the last decade &#40;58&#46;5&#37; vs 45&#46;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Twenty-one percent of the patients required evacuation of the lesions detected by computed tomography &#40;CT&#41;&#44; and 39&#37; presented severe diffuse encephalic injury &#40;DEI&#41;&#46; Seventy-nine percent of the patients in whom intracranial pressure &#40;ICP&#41; was monitored presented intracranial hypertension&#46; Sequelae of clinical relevance were recorded in 59 patients &#40;39&#37;&#41;&#44; and proved serious in 64&#37; of the cases&#46; The mortality rate in this patient series was 24&#46;7&#37;&#46; Intracranial hypertension decreased significantly in the last decade &#40;88&#37; vs 54&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; and clinical recovery has improved &#40;23&#46;3&#37; vs 63&#46;1&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; The incidence of traffic accidents has decreased in the last decade in the studied population&#59; &#40;b&#41; patients with SHI in which ICP was monitored showed a high incidence of intracranial hypertension&#59; &#40;c&#41; morbidity&#8211;mortality among pediatric patients with SHI has decreased over the course of the study period&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Describir las caracter&#237;sticas epidemiol&#243;gicas&#44; cl&#237;nicas y evolutivas de los pacientes pedi&#225;tricos con traumatismo craneoencef&#225;lico grave &#40;TCEG&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Material y m&#233;todo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n de los pacientes ingresados en una unidad de medicina intensiva pedi&#225;trica &#40;UMIP&#41; con TCEG en el periodo comprendido entre julio de 1983 y diciembre de 2009&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De los 389 pacientes con traumatismo craneoencef&#225;lico &#40;TCE&#41; ingresados en nuestra unidad durante el periodo de estudio&#44; presentaron TCEG 174 &#40;45&#37;&#41;&#46; La media de edad de este grupo fue 67<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>meses&#44; con una puntuaci&#243;n media en la escala de Glasgow &#40;GCS&#41; de 5&#44;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8 y una puntuaci&#243;n PRISM media de 10&#44;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;7&#46; La etiolog&#237;a m&#225;s frecuente de los TCEG fueron los accidentes de tr&#225;fico &#40;56&#37;&#41;&#44; aunque en la &#250;ltima d&#233;cada existe una disminuci&#243;n significativa de su incidencia &#40;el 58&#44;5 frente al 45&#44;3&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46; Un 21&#37; de los pacientes precisaron evacuaci&#243;n de la lesi&#243;n objetivada en la TC&#44; objetiv&#225;ndose en un 39&#37; lesi&#243;n encef&#225;lica difusa &#40;LED&#41; grave&#46; Un 79&#37; de los pacientes en los que se monitoriz&#243; la presi&#243;n intracraneal &#40;PIC&#41; presentaron hipertensi&#243;n intracraneal &#40;HTC&#41;&#46; Las secuelas de relevancia cl&#237;nica se objetivaron en 59<span class="elsevierStyleHsp" style=""></span>pacientes &#40;39&#37;&#41;&#44; siendo graves en el 64&#37; de ellos&#46; La mortalidad de la poblaci&#243;n estudiada fue de un 24&#44;7&#37;&#46; La incidencia de HTC fue significativamente menor en la &#250;ltima d&#233;cada estudiada &#40;el 88 frente al 54&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; con una mejor recuperaci&#243;n cl&#237;nica &#40;el 23&#44;3 frente al 63&#44;1&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">a</span>&#41; La incidencia de los accidentes de tr&#225;fico disminuy&#243; en la &#250;ltima d&#233;cada en la poblaci&#243;n estudiada&#59; <span class="elsevierStyleItalic">b</span>&#41; los pacientes con TCEG en los que se monitoriz&#243; la PIC presentaron una alta incidencia de HTC&#44; y <span class="elsevierStyleItalic">c</span>&#41; la morbimortalidad de los TCEG pedi&#225;tricos disminuy&#243; a lo largo del periodo de estudio&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; L&#243;pez &#193;lvarez JM&#44; et al&#46; Traumatismo craneoencef&#225;lico pedi&#225;trico grave &#40;I&#41;&#46; Epidemiolog&#237;a&#44; cl&#237;nica y evoluci&#243;n&#46; Med Intensiva&#46; 2011&#59;35&#58;331&#8211;6&#46;</p>"
      ]
    ]
    "multimedia" => array:6 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 896
            "Ancho" => 1667
            "Tamanyo" => 64804
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Etiology of pediatric SHIs&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 944
            "Ancho" => 1597
            "Tamanyo" => 59102
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of the GCS score in the pediatric patients with SHIs&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 861
            "Ancho" => 1583
            "Tamanyo" => 78512
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of the CT findings in the two compared study periods&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 750
            "Ancho" => 1597
            "Tamanyo" => 65802
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Percentage distribution of the modified GOS scores in the two compared study periods&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">TCDB&#44; Trauma Coma Data Bank&#59; Cranial volume&#44; under 2 years&#44; 85&#37; of the adult volume&#59; over 8 years&#44; same as in the adult&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Category&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type I diffuse brain injury &#40;DBI I&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Normal CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type II diffuse brain injury &#40;DBI II&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Small focal lesion &#40;&#60;25<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; May include bone fragments or others&#46; Midline displacement &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46; Cisterns present&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type III diffuse brain injury &#40;DBI III&#41; or swelling&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Obliteration of basal cisterns&#46; Small focal lesion &#40;&#60;25<span class="elsevierStyleHsp" style=""></span>ml&#41;&#46; Midline displacement &#60;5<span class="elsevierStyleHsp" style=""></span>mm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type IV diffuse brain injury &#40;DBI IV&#41; or shift&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Midline displacement &#62;5<span class="elsevierStyleHsp" style=""></span>mm&#46; Small focal lesion &#40;&#60;25<span class="elsevierStyleHsp" style=""></span>ml&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type V evacuated brain injury &#40;EBI V&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mass evacuated through surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Type VI non-evacuated brain injury &#40;NEBI VI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mass not evacuated &#62;25<span class="elsevierStyleHsp" style=""></span>ml&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab8741.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Classification of the brain injuries according to the CT findings &#40;TCDB criteria<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>&#41;&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Data expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#91;median&#93; or n &#40;&#37;&#41;&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">67&#46;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>41&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Males&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117 &#40;67&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Females&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57 &#40;32&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PRISM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;77<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">GCS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;5<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stay in PICU &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13 &#91;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Duration of mechanical ventilation &#40;h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>58 &#91;48&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">43 &#40;24&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab8740.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical variables of the study population&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:30 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe head injury among children&#58; prognostic factors and outcome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Bahloul"
                            1 => "B&#46;H&#46; Chokri"
                            2 => "C&#46; Hedi"
                            3 => "C&#46; Adel"
                            4 => "K&#46; Harem"
                            5 => "D&#46; Hassen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.injury.2008.04.018"
                      "Revista" => array:6 [
                        "tituloSerie" => "Injury"
                        "fecha" => "2009"
                        "volumen" => "40"
                        "paginaInicial" => "535"
                        "paginaFinal" => "540"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18703191"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of acute child and family outcome following traumatic brain injury in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V&#46;A&#46; Anderson"
                            1 => "C&#46; Catroppa"
                            2 => "F&#46; Haritou"
                            3 => "S&#46; Morse"
                            4 => "L&#46; Pentlnad"
                            5 => "J&#46; Rosenfeld"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "56009"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Neurosurg"
                        "fecha" => "2001"
                        "volumen" => "34"
                        "paginaInicial" => "138"
                        "paginaFinal" => "148"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11359102"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome after mild-to-moderate blunt head injury&#58; effects of focal lesions and diffuse axonal injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "C&#46;W&#46; Wallesch"
                            1 => "N&#46; Curio"
                            2 => "S&#46; Kutz"
                            3 => "S&#46; Jost"
                            4 => "C&#46; Bartels"
                            5 => "H&#46; Synowitz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1080/02699050010005959"
                      "Revista" => array:6 [
                        "tituloSerie" => "Brain Injury"
                        "fecha" => "2001"
                        "volumen" => "15"
                        "paginaInicial" => "401"
                        "paginaFinal" => "412"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11350654"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medical and cognitive outcome in children with traumatic brain injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Campbell"
                            1 => "S&#46; Kuehn"
                            2 => "P&#46; Richards"
                            3 => "E&#46; Ventureyra"
                            4 => "J&#46; Hutchison"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Can J Neurol Sci"
                        "fecha" => "2004"
                        "volumen" => "31"
                        "paginaInicial" => "213"
                        "paginaFinal" => "219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15198446"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Health-related quality of life during the first year after traumatic brain injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; McCarthy"
                            1 => "E&#46; McKenzie"
                            2 => "D&#46; Durbin"
                            3 => "M&#46; Aitken"
                            4 => "K&#46; Jaffe"
                            5 => "C&#46; Paidas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archpedi.160.3.252"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Pediatr Adolesc Med"
                        "fecha" => "2006"
                        "volumen" => "160"
                        "paginaInicial" => "252"
                        "paginaFinal" => "260"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16520444"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Traumatic brain injury in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "C&#46; Giza"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:3 [
                        "titulo" => "Pediatric neurology&#46; Principles and practice"
                        "edicion" => "4th ed&#46;"
                        "serieFecha" => "2006"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Actualizaciones en el manejo del traumatismo craneoencef&#225;lico grave"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "E&#46; Alted"
                            1 => "S&#46; Bermejo"
                            2 => "M&#46; Chico"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2009"
                        "volumen" => "33"
                        "paginaInicial" => "16"
                        "paginaFinal" => "30"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19232206"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatrics head injury&#58; what is unique and different"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "H&#46;E&#46; James"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Acta Neurochir"
                        "fecha" => "1999"
                        "volumen" => "73"
                        "paginaInicial" => "85"
                        "paginaFinal" => "88"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Disfunci&#243;n auton&#243;mica en el ni&#241;o con traumatismo craneoencef&#225;lico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "N&#46; Rodriguez"
                            1 => "A&#46; Febrer"
                            2 => "M&#46; Mel&#233;ndez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Neurol"
                        "fecha" => "2006"
                        "volumen" => "43"
                        "paginaInicial" => "143"
                        "paginaFinal" => "146"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16871479"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of coma and impaired consciousness&#46; A practical scale"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "G&#46; Teadsdale"
                            1 => "B&#46; Jennet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1974"
                        "volumen" => "2"
                        "paginaInicial" => "81"
                        "paginaFinal" => "84"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2567876"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assesing the conscious level of the Glasgow Coma Scale"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46;L&#46; Reilly"
                            1 => "D&#46;A&#46; Simpson"
                            2 => "R&#46; Sprod"
                            3 => "L&#46; Thomas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Child&#39;s Nerv Syst"
                        "fecha" => "1988"
                        "volumen" => "4"
                        "paginaInicial" => "30"
                        "paginaFinal" => "33"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric risk of mortality &#40;PRISM&#41; score"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;M&#46; Pollack"
                            1 => "U&#46;E&#46; Ruttimann"
                            2 => "P&#46;R&#46; Getson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "1988"
                        "volumen" => "16"
                        "paginaInicial" => "1110"
                        "paginaFinal" => "1116"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3048900"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multiple organ failure in polytrauma patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "F&#46; Faist"
                            1 => "A&#46;E&#46; Baue"
                            2 => "H&#46; Dittmer"
                            3 => "G&#46; Heberer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "1983"
                        "volumen" => "23"
                        "paginaInicial" => "775"
                        "paginaFinal" => "787"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6620431"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors for multiorgan failure&#46; A case control study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "F&#46; Henao"
                            1 => "J&#46; Daes"
                            2 => "R&#46; Dennis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Trauma"
                        "fecha" => "1991"
                        "volumen" => "31"
                        "paginaInicial" => "74"
                        "paginaFinal" => "80"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1986136"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The Traumatic Coma Data Bank&#58; design&#44; methods&#44; and baseline characteristics"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;A&#46; Foulkes"
                            1 => "H&#46;M&#46; Eisemberg"
                            2 => "J&#46;A&#46; Jane"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/jns.1991.75.1.0008"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "1991"
                        "volumen" => "75"
                        "paginaInicial" => "8"
                        "paginaFinal" => "36"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2045924"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combined continuous monitoring of systemic and cerebral oxygenation in acute brain injury&#58; preliminary observations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "J&#46; Cruz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit Care Med"
                        "fecha" => "1993"
                        "volumen" => "21"
                        "paginaInicial" => "1225"
                        "paginaFinal" => "1232"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8339591"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of outcome after severe brain damage"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "B&#46; Jennett"
                            1 => "M&#46; Bond"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1975"
                        "volumen" => "1"
                        "paginaInicial" => "480"
                        "paginaFinal" => "484"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2893908"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prognostic factors in children with severe diffuse brain injuries&#58; a study of 74 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46; Pillai"
                            1 => "S&#46;S&#46; Praharaj"
                            2 => "A&#46; Mohanty"
                            3 => "V&#46;R&#46; Kolluri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "56002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Neurosurg"
                        "fecha" => "2001"
                        "volumen" => "34"
                        "paginaInicial" => "98"
                        "paginaFinal" => "103"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11287810"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pediatric neurointensive care&#58; 2008 Update for the Rogers&#8217; Textbook of pediatric intensive care"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46; Kochanek"
                            1 => "R&#46; Tasker"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/PCC.0b013e3181ab88cd"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Crit Care Med"
                        "fecha" => "2009"
                        "volumen" => "10"
                        "paginaInicial" => "517"
                        "paginaFinal" => "523"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19584637"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants&#44; children and adolescents"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;D&#46; Adelson"
                            1 => "S&#46;L&#46; Bratton"
                            2 => "N&#46;A&#46; Carney"
                            3 => "R&#46;M&#46; Chessnut"
                            4 => "H&#46;E&#46; Du Coudray"
                            5 => "B&#46; Goldstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/01.CCM.0000066600.71233.01"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "4"
                        "paginaInicial" => "S2"
                        "paginaFinal" => "S4"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12847337"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Childhood head injury&#58; causes&#44; outcome and outcome predictors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "T&#46; Odeboe"
                            1 => "A&#46; Abubakar"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00383-004-1196-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Surg Int"
                        "fecha" => "2004"
                        "volumen" => "20"
                        "paginaInicial" => "348"
                        "paginaFinal" => "352"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15179518"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictors of outcome in severely head-injured children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; White"
                            1 => "Z&#46; Farukhi"
                            2 => "C&#46; Bull"
                            3 => "J&#46; Christensen"
                            4 => "T&#46; Gordon"
                            5 => "C&#46; Paidas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Crit care Med"
                        "fecha" => "2001"
                        "volumen" => "29"
                        "paginaInicial" => "534"
                        "paginaFinal" => "540"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11373416"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prognostic factors and outcome of children with severe head injury&#46; An 8-year experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Chiaretti"
                            1 => "M&#46; Piastra"
                            2 => "S&#46; Pulitano"
                            3 => "D&#46; Pietrini"
                            4 => "G&#46; De Rosa"
                            5 => "R&#46; Barbaro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Child&#39;s Nerv Syst"
                        "fecha" => "2002"
                        "volumen" => "18"
                        "paginaInicial" => "129"
                        "paginaFinal" => "136"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Longitudinal neuropsychological outcome in infants and preschoolers with traumatic brain injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Edwing"
                            1 => "J&#46;M&#46; Fletcher"
                            2 => "H&#46;S&#46; Levin"
                            3 => "D&#46;J&#46; Francis"
                            4 => "K&#46; Davidson"
                            5 => "M&#46;E&#46; Miner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Int Neuropsychol Soc"
                        "fecha" => "1997"
                        "volumen" => "3"
                        "paginaInicial" => "581"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9448371"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Head injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R&#46; Gedeit"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Rev"
                        "fecha" => "2001"
                        "volumen" => "22"
                        "paginaInicial" => "118"
                        "paginaFinal" => "124"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11283324"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants&#44; children and adolescents&#46; Chapter 5&#58; Indication for intracranial pressure monitoring in pediatric patient with severe traumatic brain injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;D&#46; Adelson"
                            1 => "S&#46;L&#46; Bratton"
                            2 => "N&#46;A&#46; Carney"
                            3 => "R&#46;M&#46; Chessnut"
                            4 => "H&#46;E&#46; Du Coudray"
                            5 => "B&#46; Goldstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "4"
                        "paginaInicial" => "S20"
                        "paginaFinal" => "S25"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Traumatismo craneoencef&#225;lico grave en el paciente pedi&#225;trico&#46; Evaluaci&#243;n de la neuroimagen y monitorizaci&#243;n de la presi&#243;n intracraneal como factores pron&#243;stico"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Fern&#225;ndez"
                            1 => "A&#46; Palomeque"
                            2 => "F&#46;J&#46; Cambra"
                            3 => "J&#46; Ortega"
                            4 => "J&#46;M&#46; Costa"
                            5 => "J&#46; Caritg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2001"
                        "volumen" => "25"
                        "paginaInicial" => "8"
                        "paginaFinal" => "13"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Traumatismo craneoencef&#225;lico pedi&#225;trico grave&#46; Factores predictores de mortalidad"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;M&#46; L&#243;pez"
                            1 => "J&#46;M&#46; Limi&#241;ana"
                            2 => "A&#46; Jim&#233;nez"
                            3 => "E&#46; Consuegra"
                            4 => "A&#46; Mor&#243;n"
                            5 => "R&#46; Gonz&#225;lez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2003"
                        "volumen" => "27"
                        "paginaInicial" => "155"
                        "paginaFinal" => "161"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines for the acute medical management of severe traumatic brain injury in infants&#44; children and adolescents&#46; Chapter 17&#58; Critical pathway for the treatment of estabilished intracranial hypertension in pediatric traumatic brain injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;D&#46; Adelson"
                            1 => "S&#46;L&#46; Bratton"
                            2 => "N&#46;A&#46; Carney"
                            3 => "R&#46;M&#46; Chessnut"
                            4 => "H&#46;E&#46; Du Coudray"
                            5 => "B&#46; Goldstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Pediatr Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "4"
                        "paginaInicial" => "S66"
                        "paginaFinal" => "S68"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Outcome in children with severe head injuries"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46; Esparza"
                            1 => "J&#46; Portillo"
                            2 => "M&#46; Sarabia"
                            3 => "J&#46; Yuste"
                            4 => "R&#46; Roger"
                            5 => "E&#46; Lmas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Child&#39;s Nerv Syst"
                        "fecha" => "1985"
                        "volumen" => "1"
                        "paginaInicial" => "109"
                        "paginaFinal" => "114"
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/21735727/0000003500000006/v1_201212101034/S2173572711000178/v1_201212101034/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "404"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Originals"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/21735727/0000003500000006/v1_201212101034/S2173572711000178/v1_201212101034/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572711000178?idApp=WMIE"
]

Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2011.02.002

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	9	7	16
2024 October	40	39	79
2024 September	36	31	67
2024 August	48	42	90
2024 July	33	27	60
2024 June	26	39	65
2024 May	32	30	62
2024 April	36	22	58
2024 March	36	15	51
2024 February	33	41	74
2024 January	36	37	73
2023 December	27	27	54
2023 November	18	20	38
2023 October	24	16	40
2023 September	25	36	61
2023 August	21	8	29
2023 July	26	19	45
2023 June	29	12	41
2023 May	14	22	36

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter