Hyperglycemia in pediatric head trauma patients: a cross-sectional study.
ABSTRACT To verify the prevalence of acute hyperglycemia in children with head trauma stratified by the Glasgow coma scale (GCS).
A prospective cross-sectional study carried out with information from medical records of pediatric patients presenting with head injury in the emergency room of a referral emergency hospital during a one year period. We considered the cut-off value of 150 mg/dL to define hyperglycemia.
A total of 340 children were included and 60 (17.6%) had admission hyperglycemia. Hyperglycemia was present in 9% of mild head trauma cases; 30.4% of those with moderate head trauma and 49% of severe head trauma. We observed that among children with higher blood glucose levels, 85% had abnormal findings on cranial computed tomography scans.
Hyperglycemia was more prevalent in patients with severe head trauma (GCS <8), regardless if they had or not multiple traumas and in children with abnormal findings on head computed tomography scans.
- SourceAvailable from: Fatemeh Salamat[Show abstract] [Hide abstract]
ABSTRACT: Hyperglycemia is a common secondary insult associated with an increased risk of mortality and poor outcome in traumatic brain injury (TBI), but the effect of hyperglycemia on outcomes of severe TBI in children and adolescents is less apparent. The aim of this study was to evaluate the association of hyperglycemia with mortality in pediatric patients with severe TBI. In this cross-sectional study, data of all children and adolescents with severe TBI admitted to Poursina Hospital in Rasht, including age, gender, Glasgow Coma Scale (GCS) upon admission, mortality rate, hospital length of stay, and serial blood glucose during the first three consecutive ICU days following admission, were reviewed from April 2007 to May 2011. After univariate analysis and adjustment for related covariates, logistic regression model was established to determine the association between persistent hyperglycemia and outcome. One-hundred and twenty-two children were included with a median admission GCS of 6 (interquartile range (IQR) 5-7) and a median age of 13 years (IQR 7.75-17). Among them, 91 were boys (74.6 %) and 31 were girls (26.6 %); the overall mortality was 40.2 % (n = 49). Patients who died had a significantly greater blood glucose levels than survivors for the first 3 days of admission (P = 0.003, P < 0.001, P = 0.001, respectively). Moreover, persistent hyperglycemia during the first 3 days of admission had an adjusted odds ratio of 11.11 for mortality (P < 0.001). Early hyperglycemia is associated with poor outcome, and persistent hyperglycemia is a powerful and independent predictor of mortality in children and adolescents with severe TBI.Child s Nervous System 04/2012; 28(10):1773-7. · 1.24 Impact Factor
Arq Neuropsiquiatr 2009;67(3-B):804-806
HYPERGLYCEMIA IN PEDIATRIC
HEAD TRAUMA PATIENTS
A cross-sectional study
José Roberto Tude Melo1, Rodolfo Casimiro Reis2, Laudenor Pereira Lemos-Júnior2,
Henrique Miguel Santos Coelho2, Carlos Eduardo Romeu de Almeida2, Jamary Oliveira-Filho3
Abstract – Objective: To verify the prevalence of acute hyperglycemia in children with head trauma stratified
by the Glasgow coma scale (GCS). Method: A prospective cross-sectional study carried out with information
from medical records of pediatric patients presenting with head injury in the emergency room of a referral
emergency hospital during a one year period. We considered the cut-off value of 150 mg/dL to define
hyperglycemia. Results: A total of 340 children were included and 60 (17.6%) had admission hyperglycemia.
Hyperglycemia was present in 9% of mild head trauma cases; 30.4% of those with moderate head trauma
and 49% of severe head trauma. We observed that among children with higher blood glucose levels, 85% had
abnormal findings on cranial computed tomography scans. Conclusion: Hyperglycemia was more prevalent
in patients with severe head trauma (GCS ≤8), regardless if they had or not multiple traumas and in children
with abnormal findings on head computed tomography scans.
Key WordS: adolescents, children, head trauma, hyperglycemia, prevalence.
Hiperglicemia em pacientes pediátricos com traumatismo craniencefálico: estudo de corte transversal
Resumo – Objetivo: Verificar a prevalência de hiperglicemia aguda em crianças vítimas de trauma
craniencefálico, de acordo com a escala de coma de Glasgow (GCS). Método: estudo prospectivo, de
corte transversal realizado por meio do acompanhamento de prontuários médicos de pacientes na faixa
etária pediátrica admitidos na unidade de urgência de um hospital de referência vítimas de traumatismo
craniencefálico, durante um ano. Consideramos o valor de corte em 150 mg/dL para definição de
hiperglicemia. Resultados: 340 crianças foram incluídas no estudo e 60 (17,6%) apresentaram hiperglicemia
na admissão. Hiperglicemia esteve presente em 9% dos casos de trauma craniano leve, 30,4% daqueles com
trauma craniano moderado e em 49% dos pacientes com trauma craniano grave. Verificamos que, entre as
crianças com níveis elevados de glicemia, 85% apresentavam alterações radiológicas verificadas na tomografia
computadorizada do crânio. Conclusão: A hiperglicemia foi mais prevalente em pacientes com traumatismo
craniano grave (GCS ≤8), assim como naqueles com alterações identificadas na tomografia computadorizada
do crânio, independente da presença de politraumatismo.
pALAVrAS-CHAVe: adolescentes, crianças, trauma craniocerebral, hiperglicemia, prevalência.
1post-Graduation program in Medicine and Health from Federal University of Bahia (ppgMS-UFBA), Neurosurgeon, phd student in Medicine, ppgMS-
UFBA, Salvador BA, Brazil; 2Medical Students, UFBA; 3Neurologist, phd in Neurology, University of São paulo, São paulo Sp, Brazil. There was no conflict
of interest; Without sources of funding.
received 22 March 2009, received in final form 30 June 2009. Accepted 11 July 2009.
Dr. José Roberto Tude Melo – Hospital Universitário Professor Edgard Santos/UFBA - Rua Augusto Viana sn / 2º andar - 40110-060 Salvador BA - Brasil.
Guidelines for diabetes diagnosis and classification are
widely described1,2. However, high blood glucose is com-
mon in acutely ill neurological patients, even in non-dia-
betics ones. A consensus regarding the cut-off blood glu-
cose level that would be related to a poor prognosis in
children and adolescents with head trauma is still lacking,
which makes the comparison of different studies partic-
Arq Neuropsiquiatr 2009;67(3-B)
pediatric head trauma: hyperglycemia
Melo et al.
Some authors believe that patients with hypergly-
cemia generally have a low Glasgow Coma Scale (GCS)
score3-6, poor neurological prognosis (based on GCS) and
a history of severe trauma with significant brain injury6,7. It
is well known that such acute hyperglycemia is a result of
catecholamine’ effects8,9. Some authors, however, disagree
on the association of hyperglycemia and poor prognosis,
particularly in children and adolescents, as high blood glu-
cose levels are transient and basically reflect a body re-
sponse after injury10.
In the present study we aimed to verify the prevalence
of acute hyperglycemia in pediatric patients with head
trauma, according to the severity of head injury.
Study design and data collection
A prospective cross-sectional study was carried out with
information derived from medical records of pediatric patients
with head trauma. data collected from medical records includ-
ed age, sex, mechanism of injury, classification of trauma (iso-
lated head trauma or multiple trauma), GCS score and blood
glucose level on admission and cranial computed tomography
(CCT) scan results.
Medical records of patients aged from 0 to 18 years-old
with head trauma presented in the emergency room of a refer-
ral emergency Hospital in Salvador, Bahia, Brazil, from May 2007
to July 2008 were evaluated. World Health organization (WHo)
definition for pediatric age was used here11. Severity of head trau-
ma was accessed by GCS score on admission, and when necessary
the modification for use in children under 2 years12-14. Findings
on the CCT scan considered to be abnormal included any brain
lesion such as brain swelling, diffuse axonal injury and intracra-
nial hemorrhages. The CCT scans were done in the same hospi-
tal and at the same model of tomography machine. The results
were checked by experienced radiologists and neurosurgeons.
exclusion criteria included a previous diagnosis of diabetes,
absence of GCS score, CCT scan or blood glucose levels on the
first 24h of admission and hospital stay less than 48h.
Blood glucose levels were determined by capillary blood
glucose obtained through fingertips’ puncture at hospital ad-
mission. The results were shown in digital blood glucose moni-
tor. This same technique was used in every patient. We consid-
ered values above 150mg/dl as hyperglycemia, like other authors
have already claimed3.
Ethical concerns and data analyses
The study was approved by the Hospital ethics Commit-
tee under registration no 06/07. either parents or other legal-
ly responsibles signed informed consent before inclusion in the
study. No extra exams, besides the ones usually performed in an
emergency room, were done.
Categorical data were analyzed by using χ2 analyses and
pearson analysis was used to verify correlation between GCS
and blood glucose level on admission.
A total of 340 patients were eligible for inclusion.
Mean age was 9.8 (±6) years; 73.2% were male. regard-
ing the type of trauma, the most frequent were fall from
a height (34.1%) and vehicle-pedestrian accidents (18.2%).
regarding the GCS classification, 245 (72.1%) patients had
mild head trauma (GCS 13–15), 46 (13.5%) had moderate
head trauma (GCS 9–12), whereas 49 (14.4%) suffered se-
vere head trauma (GCS 3–8).
Concerning blood glucose levels on admission, 60
(17.6%) patients had hyperglycemia. Hyperglycemia was
found in 73.3% of male patients and 55% of traffic acci-
dents victims. The prevalence of hyperglycemia increased
proportionally to the head trauma severity: 9% in mild
head trauma, 30.4% in moderate head trauma (p<0.01
when compared to mild head trauma) and 49% in cases
considered severe (p<0.01 when compared to mild head
trauma). An inverse relationship between admission glu-
cose levels and GCS score was found, using pearson anal-
ysis (r=0.32; p=0.01).
regarding the cases of isolated head trauma or mul-
tiple traumas, in those with isolated head injury we ob-
served hyperglycemia in 15% versus 20% of the other
group (p=0.28). Brain swelling (32%), and intracranial hem-
orrhages (20%) were the most important abnormal find-
ings on CCT scan. Among hyperglycemic patients, 85% had
abnormal brain parenchymal findings. However only 35.6%
of the normoglycemic patients had abnormal brain paren-
chymal findings according CCT scans results.
In accordance with previous studies15, our findings
showed the predominance of male sex and falls in pe-
diatric head trauma victims. We did not observe statis-
tical differences in hyperglycemia prevalence regarding
sex (p=0.98) and type of trauma. regarding the GCS clas-
sification, we find a preponderance of mild head trauma
victims, which is also widely described in previous stud-
ies. It is important to notice that patients with mild head
trauma generally stay in hospital for short periods of time,
have less severe or no brain damage and do not suffer a
meaningful metabolic response related to trauma16, so it is
not usual to diagnose hyperglycemia in those patients.
Hyperglycemia is indeed more frequently observed
in severe head trauma victims and in those that suffered
multiple trauma, according to some studies3,4,6,17,18. The ex-
planation would be that these patients have a more im-
portant metabolic response to injury due to the effects of
cortisol, glucagon and epinephrine release, causing intrac-
Arq Neuropsiquiatr 2009;67(3-B)
pediatric head trauma: hyperglycemia
Melo et al.
ellular acidosis, lactate accumulation, high blood glucose
levels and neuronal injury6,19-21. Therefore, our data are in
accordance with the results from other authors who corre-
late the head trauma severity and the metabolic response
to trauma, particularly higher blood glucose levels7,22,23.
Some studies show that hyperglycemia is associated with
a worse outcome, regardless of injury characteristics24.
We did not observe statistically significant differenc-
es in blood glucose levels in patients with isolated head
injury and in the ones with multiple traumas. The proba-
ble cause might be that we considered multiple trauma
any kind of injury associated with head trauma, regardless
of the degree of injury. We could have overestimated the
amount of multiple trauma victims.
The observation of abnormal CCT findings was more
frequent in hyperglycemic patients. Such an association
was also described by previous studies and possible ex-
planations would be that brain injury evokes a metabolic
response that results in hyperglycemia and/or that hyper-
glycemia itself is responsible for more meaningful brain
lesions on CCT scans25,26. our knowledge up to now does
not permit to conclude if a high blood glucose level is a
mediator or a marker of brain injury.
Inclusion the prevalence of hyperglycemia is higher in
patients with severe head trauma, as well as in those with
abnormal findings on CCT scans. All these variables are
generally associated with significant brain tissue lesion.
We cannot conclude if the higher blood glucose levels are
responsible for poorer outcomes in the present observa-
tion. The meaning of hyperglycemia in the outcomes of
children and adolescents with severe head trauma will be
analyzed in a future study.
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