[Parental presence during invasive procedures in the emergency department]. / ¿Deberían estar presentes los padres durante los procedimientos invasivos en urgencias?

Over the last decades, health care has been moving away from the paternalistic model, to one of family-centered care. In the pediatric emergency department, this new trend has led to parents playing a larger role in the health care of children, particularly during invasive procedures and/or resuscitation. Despite the increased attention to family presence, it remains a controversial topic, especially among emergency medical staff. Several studies have been performed that look at the advantages and disadvantages of this new way of conceiving child health care. To our knowledge, there is only one Spanish article on this topic, which is the reason why we performed a literature review on family presence in the emergency department.

[Multicentre study on risk factors of injuries in car crashes]. / Estudio multicéntrico sobre factores de riesgo de lesiones en accidentes de automóvil.

INTRODUCTION: Traffic accidents are the main cause of death in children between 2 and 14 years in developed countries. We analysed their clinical repercussions, epidemiological characteristics, use and suitability of Child Restraint Systems (CRS) and its correlation with the type of injuries in children less than 12 years old. MATERIAL AND METHODS: Multicentre descriptive prospective study. The following data was collected: personal details of the victims and the type of accident, use and suitability of the CRS, classification of injuries according to location and severity, need for hospitalisation, medical treatment received, use of Emergency Services and final destination of the injured. RESULTS: A total of 366 patients were studied, with a sex ratio of 1:1 and a mean age of 6 years. Of these, 69.7% had some injury (slight 92.3%). A total of 81.1% affected the head and neck, and 77.9% used some type of CRS (suitable only in 55.7%). CRS were used more in >6 year olds (27.1%-P<0.001). Driving long distances (odds ratio 6.7) and not using a suitable CRS (odds ratio 3.7) were associated with the severity of the injuries. The age of the patients and the position within the automobile were not related. All the patients with a Glasgow less than 8 and all the deceased were using an unsuitable CRS. The hospitalization rate was 8.7% and the mortality rate at 24h was 0.8%. CONCLUSIONS: An important percentage of the injured children do not use suitable child restraint systems. Non-use of a CRS or its inadequate use is a risk factor of morbidity in the traffic accidents in childhood.

[Acute ethanol intoxication in a paediatric emergency department]. / Consultas por intoxicación etílica aguda en un servicio de urgencias pediátricas.

INTRODUCTION AND AIM: Patients arriving in Paediatric Emergency Departments due to alcohol abuse is fairly common. The aim of this study is to determine the profile of the patients seen in the emergency room for acute ethanol intoxication. MATERIAL AND METHOD: A descriptive study was performed on all patients seen in the emergency department with an acute ethanol intoxication over a 12-month period (2007). Patients with accidental poisoning or with related chronic illness were excluded. RESULTS: A total of 104 patients were included (50% males). Their mean age was 16.2 years (standar desviation [SD] 1.2 years); 95.8% were older than 14 years. There was on patient who was seen twice for the same reason. The majority, 72.4%, were seen on holiday days; 82.9%, from 8:00 pm to 8:00 am. A total of 81.9% of the patients were brought in by ambulance. No cases of hypoglycaemia were detected and 7.5% of the patients had hypothermia. Ethanol levels and urine toxicology were measured in 66 cases. The mean blood ethanol was 186.1mg/dl (SD 56.2mg/dl); 21.2% were slightly intoxicated, 75.8% moderate and 3% severe. Cannabis was detected in seven cases and amphetamines in three. Three patients needed hospital admission. CONCLUSIONS: The profile of the patient who arrives to emergency department with acute ethanol intoxication is a teenager who is seen on holiday nights, after a consumption of high proof alcoholic drinks, presents a moderate intoxication, and does not require hospitalisation.

[Adolescent drug use. Ethical dilemma in the diagnostic-therapeutic approach]. / 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.

[Registry of mild craniocerebral trauma: multicentre study from the Spanish Association of Pediatric emergencies]. / 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.

[Violence and adolescence. A perspective from and Emergency Department]. / Violencia y adolescencia. Perspectiva desde un servicio de urgencias.

INTRODUCTION AND AIM: The acts of violence between adolescents are becoming increasingly more common, generating problems of a diverse nature. The knowledge of the circumstances that surround this violence is important to implement measures to decrease their incidence. The aim of this study was to describe the epidemiology of violent assault in teenagers from the perspective of an Emergency Department. MATERIAL AND METHOD: Retrospective analysis of information recorded on adolescent victims of assault, who attended our Emergency Department over a 1 year period (2006), was performed. RESULTS: Of the 105 patients included, the mean age of the assault victims was 15.9 (SD: 1.4) years. Of those, 73.3 % were male. They were seen at holidays (58.1 %) and predominantly between the hours of 8 pm and 4 am (55.2 %). Forty-nine (46.7 %) of the events were classified as fights, 44 (41.9 %) as assaults, 7 (6.7 %) as physical abuse and 5 (4.8 %) as sexual abuse. Overall, 20 (19 %) patients reported that there was a weapon at the scene: in 13.3 % a blunt object and in 5.7 % a knife/piercing object. Bruises or haematomas were present in 93.3 % of patients; lacerations in 19 % and fractures in 11.4 %. Sixty-two (59 %) patients needed an X-ray, 10 (9.5 %) a urineanalysis and 7 (6.7 %) a blood test. Seven (6.7 %) patients were hospitalised and 6 (5.7 %) were evaluated by Social Work. CONCLUSIONS: The knowledge of the epidemiology of this problem and awareness by the professionals involved in handling this, must promote the coordinated creation of protocols and actions that can decrease its impact among adolescents, and in turn, society.

[Usefulness of acid-base and electrolyte balance in acute gastroenteritis]. / Utilidad del equilibrio ácido-base y del ionograma en el tratamiento de la gastroenteritis aguda.

INTRODUCTION: Blood analysis blood is frequently requested for evaluating patients with acute gastroenteritis who come to our emergency department, but there are few studies that determine its real usefulness in the management of these patients. OBJECTIVES: a) To determine the reasons why paediatricians request laboratory tests in patients with acute gastroenteritis; b) to establish the type and frequency of laboratory abnormalities found in these patients; c) to evaluate the ability of paediatricians to predict laboratory abnormalities in children with acute gastroenteritis from the history and physical examination; d) to assess the frequency with which these laboratory findings change the initial management of the patient, and e) to determine whether there is an association between clinical and analytical results, and length of hospital stay. PATIENTS AND METHODS: Over a period of 4 months, children between 3 months and 18 years with symptomatic acute gastroenteritis seen in the emergency department and had laboratory tests requested by the paediatrician were included. RESULTS: Of the 4,172 children seen with acute gastroenteritis, 163 patients who had laboratory tests done were included in the study. The most common reason for requests was clinical suspicion of dehydration in 67.5 %. Abnormal results were seen in 77.9 % of cases, mainly metabolic acidosis (72.4 %). The sensitivity analysis to predict an analytical abnormality was 64.6 % with a specificity of 61.1 %. Electrolyte disorders caused a change in the initial management in 12.3 % of patients, with 85.3 % of patients requiring hospital admission; bicarbonate, sodium, creatinine and urea values correlated with a hospital stay of more or less 24 hours. CONCLUSIONS: History and physical examination have limitations in predicting the presence of clinically significant electrolyte abnormalities in patients without clinical signs of dehydration or mild dehydration. Some laboratory tests correlate well with the length of patient stay in hospital.

[Impact of pneumococcal vaccination on the management of infants with fever according to vaccination rates]. / Impacto de la vacunación neumocócica en el manejo del lactante con fiebre, en relación al porcentaje de vacunación.

OBJECTIVE: To calculate the impact of the heptavalent pneumococcal conjugate vaccine (PCV-7) in the management of fever without source (FWS) in infants according to vaccination rates. METHODS: The rate of pneumococcal vaccination in infants visiting 14 pediatric emergency departments (PEDs) was calculated. For the statistical analysis, two groups were established; group A: hospitals with vaccination rates of > or = 40%, and group B: hospitals with vaccination rates of < 40 %. A survey was carried out among pediatricians from 14 PEDs on the specific management of two hypothetical clinical cases of FWS (case 1: 7-month-old girl; case 2: 20-month-old girl) depending on their pneumococcal vaccination status (no vaccination, 1 o 2 doses, or 3 doses). RESULTS: In February 2005, data were collected in 1357 patients, aged 3 to 36 months; 568 (41.86 %) had received at least one dose of PCV-7. A total of 235 questionnaires were collected, 104 in group A and 131 in group B. Pneumococcal vaccination would lead (with statistically significant differences) to fewer diagnostic tests (complete blood cell counts and blood culture). This decrease would be more pronounced in group A than in group B (56.7 % vs 26.7 % and 55.8 vs 26.7 % in case 1 and 54.8 % vs 26 % and 57.7 vs 13.7 %, case 2, respectively), p < 0.05. Infants who had received complete pneumococcal vaccination would receive fewer antibiotics and would be more likely to be discharged directly from hospital (p < 0.001). CONCLUSIONS: In the previously vaccinated infant with FWS, there would be a significant reduction in the number of diagnostic tests, need for observation in the PED, rates of hospitalization and antibiotic therapy. The reduction in diagnostic tests would increase in areas with higher rates of pneumococcal vaccination.

Use of a complete autologous blood recovery system (the Sorin Xtra® Autotransfusion System) during mechanical thrombectomy of extensive cerebral venous sinus thrombosis.

Background The endovascular therapy for cerebral venous sinus thrombosis (CVST) is currently accepted as a second-line treatment for patients who have failed or those in whom systemic anticoagulation is contraindicated or in a subgroup of patients presenting with rapid neurologic deterioration. A number of different mechanical and pharmacologic endovascular strategies have been reported, either as separate or combined approaches. These new catheters and aspiration systems have a high power and vacuum capacity, which carries a risk of anemization of the patient and hypovolemic shock, being necessitating the transfusion of the patient. Material and methods Because of the problems that donor blood transfusion can bring, we describe the use of a Sorin Xtra® Autotransfusion System (ATS). This complete autologous blood recovery system was designed for use in procedures where medium- to high-volume blood loss occurs, such as major surgeries. We have adapted it to recover all the blood aspirated during the mechanical thrombectomy procedures of the dural cerebral venous sinuses, since they are procedures that can cause a significant loss of blood. One advantage to this is the patient receives his or her own blood instead of donor blood, so there is no risk of contracting outside diseases or transfusion reactions. Conclusions This technical note describes a novel and previously unpublished technical approach to CVST that can be immediately applied to clinical practice. It also raises awareness among the interventional neuroradiologist and anesthesiologist communities about novel, potentially lifesaving endovascular treatments in patients with extensive CVST.

[Neonatal management in the emergency department of a tertiary children's hospital]. / Asistencia a neonatos en el servicio de urgencias de un hospital pediátrico terciario.

OBJECTIVE: To determinate the chief complaints in neonates presenting to a pediatric emergency service and their management. MATERIAL AND METHODS: We performed a retrospective study of patients younger than 28 days old who presented to the pediatric emergency department in 2003. Patients directly admitted to the neonatal unit and those attended by the surgery and orthopedic surgery departments were excluded. Information on sex, age, time and date, waiting time, visit duration, source of referral, presenting complaint, complementary examinations, final diagnosis, and hospital admission were analyzed. RESULTS: There were 1,481 neonatal visits. The mean chronological age was 15.8 days and 57.3 % were boys. Visits were most frequent on Fridays, evening shifts, and in July and December. The most frequent chief complaints were crying/irritability (16.3 %), fever (13.6 %), vomiting (11 %), and influenza (10.8 %). The most frequent final diagnoses were feeding problems (12.6 %), infantile colic (12.4 %), and upper respiratory tract infections (12 %). No abnormalities were detected in 11.7 % of the patients and complementary examinations were not required in 45.9 %. The admission rate was 26 %, most commonly due to fever and bronchiolitis. CONCLUSIONS: Many visits were due to minor problems that did not require complementary examinations and could have been resolved in primary care. Because of the greater vulnerability of this age group, thorough investigation is required to rule out severe disease. This phenomenon was reflected by the large number of complementary examinations and admissions.

[Anesthesia in 2 cases of resection of a renal tumor involving the vena cava]. / Anestesia en dos casos de resección de un tumor renal con extensión a la vena cava.

Renal tumors can be associated with a thrombus that affects the renal vein and even the inferior vena cava. Radical surgery may require a 2-phase approach involving different anesthetic techniques: an abdominal approach for removal of the kidney and a thoracic approach for extraction of the thrombus, with extracorporeal circulation and in some cases cessation of blood circulation. We present 2 cases in which nephrectomy and thrombectomy were carried out with the support of extracorporeal circulation. The thrombus was in the renal vein and the inferior vena cava, extending to the outlet to the right atrium in both cases. In 1 case a portion reached the bifurcation of the pulmonary artery. The operation was performed under hypothermia to reduce circulation and did not require aortic clamping, cardioplegia, or cessation of blood flow.

Unwanted detachment of the Solitaire device during mechanical thrombectomy in acute ischemic stroke.

BACKGROUND: The use of retrievable stents for endovascular clot retrieval has dramatically improved successful revascularization and clinical outcome in selected patients with acute stroke. OBJECTIVE: To describe the rate and clinical consequences of unwanted spontaneous detachment of these devices during mechanical thrombectomy. METHODS: We studied 262 consecutive patients treated with the retrievable stent, Solitaire, for acute ischemic stroke between November 2008 and April 2015. Clinical, procedural, and outcome variables were compared between patients with and without unexpected detachment of this device. Detachment was classified as proximal to the stent proximal marker (type A) or distal to the marker (type B). Poor functional outcome was defined as modified Rankin scale score >2 at 90 days. RESULTS: Unwanted detachment occurred in 6/262 (2.3%) cases, four of type A and two of type B. Stent recovery was possible in three patients, all of 'type A', but in none of 'type B'. The number of prior passes was higher in patients with undesired detachment (3 (2-5) vs 2 (1-3), p=0.007). Detachment was associated with higher rate of symptomatic intracranial hemorrhage (SICH) (33.3% vs 4.3%, p=0.001), poorer outcome (100% vs 54.8%, p=0.028), and higher mortality rate at 90 days (50% vs 17%, p=0.038). CONCLUSIONS: Unwanted detachment of a Solitaire is an uncommon complication during mechanical thrombectomy in patients with acute ischemic stroke and is associated with the clot retrieval attempts, SICH, poor outcome, and higher mortality.

[Doxycycline-induced esophagitis: report of two cases]. / Esofagitis por doxiciclina. A propósito de dos casos.

Drug-induced esophagitis has frequently been reported in adults, with more than 100 substances involved. However, only a few cases occurring in the pediatric population have been published. The most frequently involved drugs are antibiotics and the incidence of esophagitis is thought to be greater than estimated due to the increase in antibiotic prescription in the last few decades. A medical history suggestive of retrosternal pain, odynophagia with or without dysphagia, and recent drug intake are suspicious for this entity. Although most cases are self-limiting, complications such as hemorrhage or perforation have been described. We present two cases of doxycycline-induced esophagitis in two teenagers that illustrate the clinical course, endoscopic pattern and treatment of this entity.

[An update of the diagnostic coding system by the Spanish Society of Pediatric Emergencies]. / Actualización del sistema de codificación diagnóstica de la Sociedad Española de Urgencias de Pediatría.

The Quality Working Group of the Spanish Society of Pediatric Emergencies (SEUP) presents an update of the diagnostic coding list. The original list was prepared and published in Anales de Pediatría in 2000, being based on the International Coding system ICD-9-CM current at that time. Following the same methodology used at that time and based on the 2014 edition of the ICD-9-CM, 35 new codes have been added to the list, 15 have been updated, and a list of the most frequent references to trauma diagnoses in pediatrics have been provided. In the current list of diagnoses, SEUP reflects the significant changes that have taken place in Pediatric Emergency Services in the last decade.

[Impact on the improvement of paediatric emergency services using a standardised model for the declaration and analysis of incidents]. / Impacto de un modelo estandarizado para la declaración y análisis de incidentes en la mejora de un servicio de Urgencias pediátrico.

INTRODUCTION: The aim of this study is to analyse changes in the incidents reported after the implementation of a new model, and study its results on patient safety. PATIENTS AND METHODS: In 2012 an observational study with prospective collection of incidents reported between 2007 and 2011 was conducted. In May 2012 a model change was made in order to increase the number of reports, analyse their causes, and improve the feedback to the service. Professional safety representatives were assigned to every department, information and diffusion sessions were held, and a new incident reporting system was implemented. With the new model, a new observational study with prospective collection of the reports during one year was initiated, and the results compared between models. RESULTS: In 2011, only 19 incidents were reported in the Emergency Department, and between June 1, 2012 to June 1, 2013, 106 incidents (5.6 times more). The incidents reported were medication incidents (57%), identification (26%), and procedures (7%). The most frequent causes were human (70.7%), lack of training (22.6%), and working conditions (15.1%). Some measures were implemented as a result of these incidents: a surgical checklist, unit doses of salbutamol, tables of weight-standardised doses of drugs for cardiopulmonary resuscitation. CONCLUSIONS: The new model of reporting incidents has enhanced the reports and has allowed improvements and the implementation of preventive measures, increasing the patient safety in the Emergency Department.

[Has the presence of parents during invasive procedures in the emergency department increased in the last few years?]. / ¿Ha aumentado la presencia de los padres durante los procedimientos invasivos en urgencias en los últimos años?

INTRODUCTION: In the recent years, parents are playing an important role in Pediatric Emergency Department (PED), and wish to be present when invasive procedures (IP) are performed. OBJECTIVES: 1) To compare the presence of parents during IP in PED in Spain between 2008 and 2012. 2) To compare the arguments to restrict the presence and problems arising from this, and 3) To determine whether the views of health personnel have changed on this subject. METHODOLOGY: A descriptive multicenter comparative study was conducted in 2008 and 2012. A total of 42 questionaires were sent by email to PED managers, with the responding hospitals being included in the 2 periods of the study. RESULTS: A total of 22 hospitals participated in the study. The presence of parents in the PED increased between 2008 and 2012 for all IP, significantly in the blood test and urine catheterization. In 2012, managers state that children are not so nervous, and anxiety of the parents and staff fear of a poorer performance, as an argument to restrict family presence. There were few problems during the 2 periods, with the poor behavior of the children decreasing. According to managers, the opinion of health personnel has not changed in the last four years. CONCLUSIONS: The presence of parents during the IP in the PED has increased in the last four years, although the presence is low for more invasive procedures. Managers argue the presence of fewer behavior problems to restrict family presence. The opinion of the staff has not changed in the last four years, although more studies are required on this issue.

[Poisonous plants: An ongoing problem]. / 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, butcher's-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.

[Predictive factors of contamination in a blood culture with bacterial growth in an Emergency Department]. / Factores predictores de contaminación ante un hemocultivo con crecimiento bacteriano en Urgencias.

INTRODUCTION: The aim of this study is to identify predictive factors of bacterial contamination in positive blood cultures (BC) collected in an emergency department. PATIENTS AND METHODS: A prospective, observational and analytical study was conducted on febrile children aged on to 36 months, who had no risk factors of bacterial infection, and had a BC collected in the Emergency Department between November 2011 and October 2013 in which bacterial growth was detected. The potential BC contamination predicting factors analysed were: maximum temperature, time to positivity, initial Gram stain result, white blood cell count, absolute neutrophil count, band count, and C-reactive protein (CRP). RESULTS: Bacteria grew in 169 BC. Thirty (17.8%) were finally considered true positives and 139 (82.2%) false positives. All potential BC contamination predicting factors analysed, except maximum temperature, showed significant differences between true positives and false positives. CRP value, time to positivity, and initial Gram stain result are the best predictors of false positives in BC. The positive predictive values of a CRP value≤30mg/L, BC time to positivity≥16h, and initial Gram stain suggestive of a contaminant in predicting a FP, are 95.1, 96.9 and 97.5%, respectively. When all 3 conditions are applied, their positive predictive value is 100%. Four (8.3%) patients with a false positive BC and discharged to home were revaluated in the Emergency Department. CONCLUSIONS: The majority of BC obtained in the Emergency Department that showed positive were finally considered false positives. Initial Gram stain, time to positivity, and CRP results are valuable diagnostic tests in distinguishing between true positives and false positives in BC. The early detection of false positives will allow minimising their negative consequences.

Difficult management of pain following sacrococcygeal chordoma: 13 months of subarachnoid infusion.

We report on a patient suffering severe pain following a long-standing sacral chordoma in whom management of therapy and pain was extremely difficult. Because orally administered morphine was observed to be ineffective in the early stages of treatment, we tried to achieve pain relief by using epidural morphine. This was also unsatisfactory. Intrathecal infusion of morphine and bupivacaine through a catheter inserted at the L2-L3 level was also found to be ineffective; only a segment block was observed. A structural anomaly of the spine was suspected and confirmed by myelography, showing metastasis at L3. Pain relief improved when an infusion of morphine+bupivacaine was employed through a catheter placed at the L4-L5 level below the blockage. A major problem which continued throughout the course of the disease was the daily occurrence of episodes of unbearable sharp pain that required addition of midazolam to the local anesthetic/opioid subarachnoid infusion. The patient received this mixture through an intrathecal port during the last 13 months of life, a gradually increasing dose being necessary. Periods of analgesia were followed by occasional crises of intense sharp pain suggesting incomplete relief. No serious complications or meningitis occurred. This case emphasizes the difficulty in managing pain in this type of cancer.