V. Trenchs Sainz de la Maza

Limitación terapéutica en cuidados intensivos

Introduccion El planteamiento de limitacion terapeutica es una opcion presente en las unidades de cuidados intensivos (UCI) ante determinados casos de pacientes en situacion critica y sin posibilidades de recuperacion o con presencia de secuelas graves. Pacientes y metodos Se analiza cual es la situacion actual de esta cuestion en Espana a traves de los datos recogidos a lo largo de un ano en 10 hospitales de referencia con UCI pediatrica. Se incluyeron 49 pacientes, 43 de los cuales sufrian enfermedades cronicas. Resultados La causa mas frecuente de ingreso en UCI en este grupo de pacientes es la insuficiencia respiratoria seguida del postoperatorio cardiaco. La familia aparece como elemento clave en la toma de esta decision a pesar de que todavia se detecta un pequeno porcentaje de casos en los que el personal sanitario actua de forma paternalista. La retirada o no instauracion de determinadas medidas de soporte vital, principalmente ventilacion mecanica y farmacos vasoactivos, asi como la no realizacion de reanimacion cardiopulmonar, son los tipos de limitacion mas utilizados. Destaca la generalizacion del uso de sedoanalgesia como elemento necesario en el cuidado del buen morir. Tras la instauracion de las medidas de limitacion terapeutica fueron dados de alta de UCI 6 pacientes. Conclusiones Dada la gran variabilidad existente en el modo de tratar los casos de limitacion terapeutica, aunque siempre debe analizarse cada caso en particular, se sugiere la necesidad de establecer pautas de actuacion comunes para facilitar la toma de decisiones en este sentido.

Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda

Introduction In recent years, the prevalence of Acute Alcohol Intoxication (AAI) in adolescents has increased. One of its impacts had been the increase in consultations in the Emergency Services (ES). The objective of this study is to assess the psychosocial profile of adolescents who consult for AAI and study their personal, family and social functioning.INTRODUCTION In recent years, the prevalence of Acute Alcohol Intoxication (AAI) in adolescents has increased. One of its impacts had been the increase in consultations in the Emergency Services (ES). The objective of this study is to assess the psychosocial profile of adolescents who consult for AAI and study their personal, family and social functioning. METHODS 104 families of adolescents who attended for AAI in ES and 104 controls, matched by age and sex, were interviewed by telephone to obtain sociodemographic, clinical, academic and family functioning data. RESULTS 72% of the adolescents who were attended for AAI were under 16 years old. Academic data showed that 37.7% had repeated a school year, 20% had truancy and 19.6% abandoned their basic studies. 9,8% were in psychiatric treatment. Only 11.4% of patients were referred to specialist service. There were no significant differences between in any of the clinical variables between the study and control group. CONCLUSIONS This study provides new information on the characteristics of this population and provides guidance on the need to develop protocols for working in the ES that includes not only biochemical/ toxicological parameters but also includes the assessment of psychosocial parameters.

Calidad de la prescripción antibiótica en un servicio de urgencias pediátrico hospitalario

INTRODUCTION Adequate antibiotic prescribing in Paediatric Emergency Departments (PEDs) is a necessity due to the high number of patients consulting for infectious diseases. The aim of this study was to evaluate the antibiotic prescription quality in a PED. MATERIAL AND METHODS Retrospective study of patients attending a PED and diagnosed with acute otitis media, pharyngotonsillitis or community-acquired pneumonia during 2008. A random sample of 100 cases for each disease was selected. The parameters employed for assessing the prescribing quality were: illness subject to being treated with antibiotics, adequate antibiotic, dosage, interval of administration and length of treatment. An error in any of these parameters was considered an inappropriate prescription. The appropriateness of the antibiotic prescriptions was assessed based on the recommendations described on our hospital protocols. RESULTS Antibiotics were prescribed to 219 patients (73%). Therapy was considered to be inappropriate in 67 children (22.3%). Unnecessary treatment was indicated in 15 cases (6.8%) and in 4 patients (2%) the antibiotic selected was incorrect. Antibiotic was not prescribed to one patient subject to being treated (1.2%). The treatment length was wrong in 22 cases (11.5%), inappropriately short in all of them, the interval of administration in 20 (10.1%) and dosage in 13 (6.5%). CONCLUSIONS The use of antibiotics was appropriate for the diseases analysed, particularly as regards to the indication and antibiotic selection. The length of the treatment was the aspect found to be most deficient. Some important measures should be undertaken in order to improve antibiotic prescription quality.

Registro de traumatismos craneoencefálicos leves: estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas

OBJECTIVE To determine management practices of minor head trauma in children evaluated at Spanish Hospital Emergency Departments and to determine patient variables associated with intracranial injury. METHODS Multicenter and prospective study during 18 months in 9 hospitals in Spain. Patients up to the age of 18 years with minor head trauma (Glasgow Coma Scale score higher than or equal to 13 on admission), treated in Emergency Departments and with a maximum onset of 72h since the traumatism, were included in the study. RESULTS A total of 1070 patients were studied with a median age of 2.4 years (p25-75 0.9-6.4 years); 61.2% were male. The median time between head trauma and medical consultation was 1 hour (p25-75 0.6-2.5h). Skull X-rays were performed on 64.5% of the children and a head CT scan on 9%; 91.4% of X-ray and 84.4% of CT were normal. The prevalence of intracranial injury was 1.4% (95% CI: 0.8-2.3). Twenty-five point three percent of the patients were admitted; 4 (3.7%) required neurosurgical intervention during admission. None of the patients died. Multiple logistic regression analysis identified loss of consciousness (OR 4.2, 95% CI: 1.1-17; P=0.045), neurological deterioration (OR 8.8, 95% CI: 2.1-37.6; P=0.003) and cephalhaematoma (OR 14.6, 95% CI: 4.9-44; P <0.001) as independent predictors of intracranial injury. CONCLUSIONS The combination of clinical parameters allows selection of patients with minor head trauma who need complementary explorations. In consequence, the routine use of skull X-ray in their initial evaluation is unnecessary.

Asistencia a neonatos en el servicio de urgencias de un hospital pediátrico terciario

Objetivo Conocer que problemas motivan las consultas de neonatos a un servicio de urgencias y determinar las caracteristicas de la atencion que se les ofrece. Material y metodos Revision retrospectiva de los informes de urgencias de los neonatos atendidos durante el ano 2003. Se excluyen los pacientes que ingresaron directamente en el Servicio de Neonatologia y los atendidos por las secciones de Cirugia y Traumatologia. Se analizan edad, sexo, hora y fecha de llegada, tiempo de espera y asistencia, derivacion por otro medico/centro, motivo de consulta, exploraciones complementarias, diagnostico final y destino del paciente. Resultados Se realizaron 1.481 visitas, con edad media de 15,8 dias. El 53,7 % eran varones. La mayor presion asistencial se registro en viernes, en el turno de tarde y en los meses de julio y diciembre. El principal motivo de consulta fue llanto/ irritabilidad (16,3 %), seguido de fiebre (13,6%), vomitos (11%) y cuadro catarral (10,8%). Los diagnosticos mas frecuentes fueron: dudas de puericultura (12,6 %), colico del lactante (12,4%) e infeccion de vias respiratorias altas (12 %). En el 11,7 % de los casos no se objetivo ninguna patologia y el 45,9 % no preciso exploraciones complementarias. La proporcion de ingresos fue del 26 %, principalmente por fiebre sin foco y bronquiolitis. Conclusiones Muchas consultas corresponden a patologia menor que no precisan exploraciones complementarias y podrian ser resueltas en centros de atencion primaria. La alta vulnerabilidad de la etapa neonatal requiere de una valoracion minuciosa por la posibilidad de procesos graves, dato reflejado en la elevada proporcion de pruebas diagnosticas e ingresos.

Consumo de drogas en adolescentes. Dilema ético en el abordaje diagnóstico-terapéutico

Illegal drug use among adolescents has increased in recent years in Spain, as well as has the risk behaviours and problems typical of adolescence. The results of studies on drug use during this stage of life reveal the serious and wide-ranging consequences that can arise. Emergency services are often the first to receive and deal with these and its professionals must face situations that pose contradictions between two of the basic ethical principles, the principle of autonomy and the principle of beneficence; an ethical dilemma that is addressed in this work.

Lesión medular aguda en edad pediátrica

Introduccion La lesion medular aguda es una entidad de escasa frecuencia en edad pediatrica pero adquiere especial relevancia debido a las graves secuelas y a las prolongadas estancias que provoca. Objetivos Conocer la epidemiologia, forma de presentacion, pruebas diagnosticas, tratamiento y evolucion de las lesions medulares agudas ingresadas en un hospital pediatrico de tercer nivel. Determinar el efecto que puede tener la traqueostomia precoz en el tiempo de estancia en la Unidad. Pacientes y metodos Se trata de un estudio retrospectivo de cohortes que revisa las lesiones medulares agudas ingresadas en nuestro centro desde el ano 1992. Resultados Se recogieron 16 pacientes, 12 varones (75%) con edades al ingreso comprendidas entre las pocas horas de vida y los 19 anos. Los dias de ingreso en la unidad de cuidados intensivos oscilaron entre 12 h y 6 anos. En 4 casos la causa fue una lesion obstetrica; uno de ellos fallecio y el resto se encuentran en su domicilio con ventilacion mecanica. En 7 casos la causa fue traumatica; fallecieron 2 pacientes, otros dos residen en un centro sociosanitario y tres en su domicilio. En 2 casos la causa fue una malformacion vascular medular y los tres ultimos se presentaron en el postoperatorio inmediato de una cirugia de columna. De los 16 pacientes recogidos el 56,2% fueron traqueostomizados y el 83 % de los supervivientes residen en su domicilio. Conclusiones La realizacion precoz de la traqueostomia, la posibilidad de la ventilacion mecanica domiciliaria y la instruccion de las familias ha permitido reducir la estancia de estos pacientes en la Unidad y que puedan residir en su casa.

Tóxicos vegetales: un problema aún vigente ☆

INTRODUCTION A medical visit for plant ingestion is rare in the pediatric emergency services but may involve a high toxicity. The botanical toxicology training of health staff is often very limited, and it can be difficult to make a diagnosis or decide on the appropriate treatment. OBJECTIVE To study the epidemiological and clinical characteristics of poisoning due to plant ingestion in order to increase the knowledge of the health professional. MATERIAL AND METHODS A descriptive retrospective study was conducted on patients seen in a pediatric emergency department after the ingestion of plant substances from January 2008 to December 2012. RESULTS During the period of study, 18 patients had ingested possible toxic plants. In 14 cases, it was considered to be potentially toxic: broom, oleander, mistletoe, butchers-broom, and vulgar bean (2), Jerusalem tomato, castor (2), Jimson weed, potus, marijuana, and mushrooms with digestive toxicity (2). Among the potentially toxic cases, the ingestion was accidental in 10 patients, 2 cases were classed as infantile mistreatment, 1 case had recreational intention, and another one suicidal intentions. The ingestion of oleander, castor and Jimson weed had major toxicity. CONCLUSIONS The potential gravity of the ingestion of plant substances and the variety of the exposure mechanism requires the pediatrician to bear in mind this possibility, and to be prepared for its diagnosis and management. Specific preventive information measures need to be designed for the families and for the regulation of toxic plants in playgrounds.

Ingesta de cáusticos: situación actual y puesta al día de las recomendaciones

BACKGROUND Household product ingestion is the second cause of visiting an Emergency Department for poisoning in children. Among these products, caustics are of great interest because of their potential toxicity and risk of sequelae. OBJECTIVES To describe the epidemiological and clinical features of patients admitted to our hospital due to possible caustic ingestion. To analyse the risk factors associated with oesophageal or gastric injury. To review the latest treatment recommendations. MATERIALS AND METHODS Retrospective review of all patients admitted with suspicion of caustic ingestion between January 2005 and April 2010. Epidemiological, clinical and therapeutic aspects were recorded. RESULTS A total of 78 patients were admitted, 45 (57.7%) were male, with a median age of 2.2 years (range: 1-17.3 years). In 13 cases the product was kept in a container different than the original. In 36 children, the family had induced vomiting or had given a liquid to dilute the product. Fifty two patients were symptomatic, and 46 of them had some sign on physical examination. Thirty nine oesophagoscopies were performed, and 7 oesophageal or gastric lesions were observed. When patients with normal and abnormal endoscopic findings were compared, the factors associated with an increased risk of mucosal injury were vomiting (P=0.01), and two or more symptoms at admission (P=0.03). No complication was described in patients without endoscopy. CONCLUSIONS Family education about preventive and initial measures after caustic ingestion must be improved in an attempt to prevent wrong actions which can be harmful. Some patients might benefit from clinical observation without aggressive therapeutic measures.

Abdominalgias de causa ginecológica: una realidad en adolescentes

OBJECTIVE To determine the prevalence, the presentation, the evaluation and the evolution of abdominal pain of gynaecological cause in adolescents who came to a Paediatric Emergency Department. METHODS An observational and descriptive study was performed. All adolescent female aged 12 to 18 years who came to Emergency Service during 2008 with abdominal pain were included. The patients diagnosed with gynaecological disorders were studied. RESULTS Six hundred and ninety-nine adolescents with abdominal pain were evaluated and 54 (7,7%) of them were of gynaecological cause. Their mean age was 15,2 (SD 1,7) years. Fifty-one (94,4%) had had the menarche. Thirteen (59,3%) of the 32 adolescents, who were asked, said that they had had sex. The median evolution of pain was 2 days (p25-75: 6hours-4days). The most frequent associated symptoms were micturition syndrome (11; 20,4%) and vomiting (9; 16,7%). Thirty-one (57,4%) adolescents were evaluated by two or more specialists. Forty-two (77,7%) patients were subjected to complementary examinations; abdominal ultrasound (29; 53,7%) and urinary sediment (26; 48,1%) were the two most common. The main diagnoses were peri-ovular pain (16; 29,6%) and dysmenorrhoea (14; 25,9%). Six (9,3%) patients were admitted to the hospital and 4 (7,4%) needed surgery. CONCLUSIONS Although the main causes of abdominal pain in adolescent females are physiological, an accurate anamnesis and physical examination is essential to rule out other more serious causes. A multidisciplinary evaluation is often necessary to make a correct diagnosis.