[Children with minor head injury in the emergency department: Is skull radiography necessary for children under 2 years?]. / Niños con traumatismo craneal leve en urgencias: ¿es necesaria la radiografía de cráneo en pacientes menores de 2 años?

BACKGROUND: Current guidelines on the management of mild head trauma (traumatic brain injury/TBI) do not include the presence of a skull fracture in determining the risk of intracranial injury. However, in our setting cranial radiography is still performed frequently to rule out the presence of skull fracture. OBJECTIVE: To estimate the prevalence of clinically-important traumatic brain injuries (ciTBI) in children younger than two years of age with mild TBI. PATIENTS AND METHODS: Descriptive observational study. All children attended in emergency department with mild TBI (Glasgow ≥14 points) for a year were included. We defined ciTBI as intracranial injuries that caused death or required neurosurgery, intubation for more than 24 hours, inotropic drugs or mechanical ventilation. RESULTS: The study included 854 children, of which 457 (53.5%) were male. The median patient age was 11.0 months (P25-75: 7.5-17.0 months). In 741 cases (86.8%) the mechanism of TBI was a fall. In 438 cases (51.3%) skull radiography was performed. Eleven children (1.3%) had intracranial injury, but none met the criteria for ciTBI (estimated prevalence of ciTBI was 0%; CI 95%: 0%-0.4%). CONCLUSION: Children younger than two years of age with mild TBI have low prevalence of ciTBI. Consequently, it is possible to monitor children younger than two years with a TBI without performing skull radiography.

Impact of a Disaster Drill on Waiting Times in a Pediatric Emergency Department.

OBJECTIVE: Emergency departments should improve their preparedness for mass casualty incidents (MCIs) through periodic drills. These exercises are conducted while maintaining regular care. The aim of this study was to determine the impact of a disaster drill in a pediatric emergency department (PED) on real patients' waiting times. METHODS: On September 10, 2019, a 4-h disaster drill was conducted in the PED of a tertiary pediatric hospital, with minimal staff reinforcement (2 nurses). Cases were real patients that came to the PED during the drill. The patients that visited the PED the day before were the control group. Variables analyzed were: age, sex, destination, triage level, time-to-triage, time-to-physician, length of PED stay, and percentage of patients visited within the optimal time according to triage level. RESULTS: Sixty-eight patients (case group) and 63 patients (control group) were analyzed; both groups were comparable except for the median age. There were no differences in time-to-triage, time-to-physician, and length of PED stay between the 2 groups. The percentage of patients visited within optimal time according to triage level was higher in the case group. CONCLUSIONS: Conducting an MCI drill in the PED, with minimal staff reinforcement, was not detrimental to real patients' waiting times.

Deep vein thrombosis: rare cases of diagnoses in a pediatric emergency department.

Deep vein thrombosis (DVT) has an estimated annual incidence of 0.07/10,000 children. Early diagnosis suspicion in the emergency department is important because it is a serious disease that, if untreated, can lead to a postthrombotic disease or a pulmonary thromboembolism. We report 2 cases of DVT whose diagnosis was made in the pediatric emergency department. Case 1 is a 9-year-old boy, evaluated with corticodependent nephrotic syndrome, who presented with pain in the lower left limb and increase in size of 48 hours' evolution suggestive of DVT. The elevation of D-dimer in the blood analysis and images from the Doppler ultrasound confirmed the diagnosis. His clinical evolution was good after beginning treatment with low molecular weight heparin. Case 2 is a 16-year-old adolescent, mother of a 1-year-old infant, who took oral contraceptives and was an occasional smoker, showed increased size and had pain in the lower left limb of a few hours' evolution. Deep vein thrombosis was suspected, and the diagnosis was confirmed by Doppler ultrasound. The evolution was favorable after beginning treatment with low molecular weight heparin. Although DVT is rare in children, early detection is important, requiring a detailed case history in the presence of edematous, painful, and hot limbs that are keys to the diagnostic suspicion. The imaging test and the laboratory tests will confirm the diagnosis, and anticoagulant treatment will prevent complications.

Cannabis poisoning under the age of 3 years. / Intoxicación por cannabis en menores de 3 años.

EN: The increased use of cannabis among adults and the general perception that cannabis is harmless has been accompanied by a rise in the number of acute poisoning cases among children. We present a retrospective, descriptive study of patients aged 3 years or younger who were treated for cannabis poisoning in a pediatric emergency department between 2012 and 2017. Epidemiologic and clinical data as well as toxicologic findings are reported. We found 10 cases of cannabis poisoning in our records. Nine of the patients had diminished consciousness. Only 2 families initially reported exposure to cannabis when interviewed. Repeated exposure was demonstrated by analysis of hair from 2 patients. We conclude that cannabis poisoning should be included in the differential diagnosis of young children with acute neurologic symptoms of unknown origin. When cannabis is detected in urine samples collected in the pediatric emergency department, more specific diagnostic techniques should be used to assess the possibility of repeated exposure.

ES: El aumento en el consumo de cannabis y su trivialización por la población adulta se han traducido en un aumento de los casos de intoxicaciones agudas en niños. Se presenta un estudio observacional retrospectivo de los pacientes menores de 3 años intoxicados por cannabis entre 2012 y 2017 en un servicio de urgencias pediátricas (SUP). Se recogieron datos epidemiológicos, clínicos y toxicológicos. Se detectaron 10 intoxicaciones por cannabis. Nueve pacientes presentaron alteración en el nivel de conciencia. Solo en 2 casos la familia refirió la exposición al tóxico en la anamnesis inicial. La detección en cabello demostró exposición repetida en 2 pacientes. En conclusión, es necesario incluir la intoxicación por cannabis dentro del diagnóstico diferencial de los niños con clínica neurológica aguda no filiada. Ante la detección de cannabis en orina en el SUP, se debe solicitar la confirmación mediante técnicas específicas y valorar la posibilidad de exposiciones repetidas.

[Clinical observation: A safe alternative to radiology in infants with mild traumatic brain injury]. / Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve.

OBJECTIVE: The protocol for the management of mild cranioencephalic trauma in the emergency department was changed in July 2013. The principal innovation was the replacement of systematic X-ray in infants with clinical observation. The aims of this study were to determine whether there was, 1) a reduction in the ability to detect traumatic brain injury (TBI) in the initial visit to Emergency, and 2) a change in the number of requests for imaging tests and hospital admissions. METHODOLOGY: This was a retrospective, descriptive, observational study. Two periods were established for the study: Period 1 (1/11/2011-30/10/2012), prior to the implementing of the new protocol, and Period 2 (1/11/2013-30/10/2014), following its implementation. The study included visits to the emergency department by children≤2 years old for mild cranioencephalic trauma (Glasgow Scale modified for infants≥14) of ≤24hours onset. RESULTS: A total of 1,543 cases were included, of which 807 were from Period 1 and 736 from Period 2. No significant differences were observed as regards sex, age, mechanism, or risk of TBI. More cranial fractures were detected in Period 1 than in Period 2 (4.3% vs 0.5%; P<.001), without significant changes in the detection of TBI (0.4% vs 0.3%; P=1). However, there were more cranial X-rays (49.7% vs 2.7%; P<.001) and more ultrasounds (2.1% vs 0.4%; P<.001) carried out, and also fewer hospital admissions (8.3% vs 3.1%; P<.001). There were no significant differences in the number of computerised tomography scans carried out (2% vs 3%; P=.203). CONCLUSIONS: The use of clinical observation as an alternative to cranial radiography leads to a reduction in the number of imaging tests and hospital admissions of infants with mild cranioencephalic trauma, without any reduction in the reliability of detecting TBI. This option helps to lower the exposure radiation by the patient, and is also a more rational use of hospital resources.

[Clinical scale for the diagnosis of ventriculoperitoneal shunt malfunction in children in Emergency Department]. / Escala clínica para el diagnóstico de disfunción de válvula ventriculoperitoneal en niños en el Servicio de Urgencias.

INTRODUCTION: It is well known that some symptoms in children with ventriculoperitoneal shunt are associated with a higher risk of developing shunt malfunction. However none of those symptoms are sensitive or enough specific enough to diagnose the shunt malfunction. OBJECTIVE: To develop a diagnostic scale to identify children with an increased risk of shunt malfunction in the Emergency Department. MATERIAL AND METHODS: This is a prospective study including children aged one to eighteen years old admitted to the Emergency Department between April 2010 and March 2013 with symptoms of ventriculoperitoneal shunt malfunction. Logistic regression Analysis was used to determine whether or not the variables were considered independent risk factors for shunt malfunction. The results led to the development of a diagnostic scale. RESULTS: A scale was developed using 9 variables (erythema, swelling or discharge from the catheter trajectory, drowsiness, stiff neck, headache, afebrile, age>4 years, vomiting, recent neurological deficit, and time since last surgery ≤ 2 years) with a maximum score of 20 points. It was found that Scale scores ≥ 7 points were associated with an increased risk of shunt malfunction (OR 34.0, 95% CI 15.4-74.9; sensitivity 88.3%, specificity 81.1%, PPV 53.4%, NPV 96.7%). DISCUSSION: A diagnostic scale is designed for assessing the risk of shunt malfunction, selecting those patients with a higher risk. The use of this scale could help the management of these patients, reducing complementary tests, as well the usual radiation suffered by these children.