Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil / Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit

Objetivo Identificar factores pronósticos precoces que conduzcan a un mayor riesgo de pronóstico desfavorable. Diseño Estudio de cohortes observacional de octubre 2002 a octubre 2017. Pacientes y ámbito Se incluyeron pacientes menores de 18 años con TCE grave ingresados en cuidados intensivos (UCIP). Variables e intervenciones Se recogieron variables epidemiológicas, clínico-analíticas y terapéuticas. Se valoró la capacidad funcional del paciente a los 6 meses mediante la Glasgow Outcome Scale (GOS). Se consideró pronóstico desfavorable un GOS menor o igual a 3. Se realizó un análisis univariante para comparar grupos de buen y mal pronóstico y su relación con las diferentes variables. Se realizó un análisis multivariante para predecir el pronóstico del paciente. Resultados 98 pacientes, 61,2% varones, mediana de edad 6,4 años (RIQ 2.49–11.23). El 84,7% fueron atendidos por los servicios de emergencias extrahospitalarios. A los 6 meses, el 51% presentaba recuperación satisfactoria, 26,5% secuelas moderadas, 6,1% secuelas graves y 2% estado vegetativo. Fallecieron el 14,3%. Hubo significación estadística entre la puntuación en la escala de coma de Glasgow (ECG) prehospitalaria, reactividad pupilar, hipotensión arterial, hipoxia, ciertas alteraciones analíticas y radiológicas (compresión de las cisternas basales), con pronóstico desfavorable. El análisis multivariante demostró que es posible realizar modelos predictores de la evolución de los pacientes. Conclusiones Es posible identificar factores pronósticos de mala evolución en las primeras 24 horas postraumatismo. Su conocimiento puede ayudar a la toma de decisiones clínicas y ofrecer una mejor información a las familias (AU)

Objective To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. Design Observational cohort study from October 2002 to October 2017. Setting and patients Patients with severe TBI admitted to intensive care were included. Variables and interventions Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. Results 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49–11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. Conclusions it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families (AU)

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS less than or equal to 3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: 98 patients were included, 61.2% males, median age 6.4 years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: it is possible to identify prognostic factors of poor evolution in the first 24 h after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

Early prognostic factors for morbidity and mortality in severe traumatic brain injury. Experience in a child polytrauma unit. / Factores pronósticos precoces de morbimortalidad en el traumatismo craneoencefálico grave en niños. Experiencia en una unidad de politraumatismo infantil.

OBJECTIVE: To identify early prognostic factors that lead to an increased risk of unfavorable prognosis. DESIGN: Observational cohort study from October 2002 to October 2017. SETTING AND PATIENTS: Patients with severe TBI admitted to intensive care were included. VARIABLES AND INTERVENTIONS: Epidemiological, clinical, analytical and therapeutic variables were collected. The functional capacity of the patient was assessed at 6 months using the Glasgow Outcome Scale (GOS). An unfavorable prognosis was considered a GOS ≤3. A univariate analysis was performed to compare the groups with good and bad prognosis and their relationship with the different variables. A multivariate analysis was performed to predict the patient's prognosis. RESULTS: A total of 98 patients were included, 61.2% males, median age 6.4years (IQR 2.49-11.23). 84.7% were treated by the out-of-hospital emergency services. At 6 months, 51% presented satisfactory recovery, 26.5% moderate sequelae, 6.1% severe sequelae, and 2% vegetative state. 14.3% died. Statistical significance was found between the score on the prehospital Glasgow coma scale, pupillary reactivity, arterial hypotension, hypoxia, certain analytical and radiological alterations, such as compression of the basal cisterns, with an unfavorable prognosis. The multivariate analysis showed that it is possible to make predictive models of the evolution of the patients. CONCLUSIONS: It is possible to identify prognostic factors of poor evolution in the first 24hours after trauma. Knowledge of them can help clinical decision-making as well as offer better information to families.

[Aplastic crisis due to parvovirus B19 and Epstein-Barr virus in a patient with hereditary spherocytosis]. / Crisis aplásica por Parvovirus B19 y virus de Epstein-Barr en paciente con esferocitosis hereditaria.

Anemic syndrome in childhood requires a diagnosis and urgent treatment guided by systematic protocols that can avoid unnecessary additional testing. The case of a 4 year-old girl with fatigue and intermittent fever of 7 days duration, accompanied by abdominal pain is presented. She had regular general health status, with mucocutaneous jaundice, a grade III/VI/iv murmur, and painful abdomen with hepatosplenomegaly. The blood analysis showed a hypo-regenerative anemia with increased LDH and indirect bilirubin. The Coombs Test was negative, with spherocytes being observed in the peripheral blood smear. The IgM and IgG were positive for parvovirus B19 IgM and Epstein Barr virus, leading to the diagnosis of aplastic crisis in a patient with hereditary spherocytosis. No specific treatment was required. Under the suspicion of anemic syndrome in emergencies, the ABCDE sequence must be followed. Through the history, physical examination and basic laboratory tests, an initial diagnostic approach can be made. Specific etiological tests should be based on this first study.

Simulación de situaciones urgentes en Atención Primaria (taller instrumentalizado) / Simulation of Primary Care emergency situations (hands-on workshop)

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Caídas desde grandes alturas en Pediatría. Epidemiología y evolución de 54 pacientes / Falls from heights in Pediatrics. Epidemiology and evolution of 54 patients

Objetivo: Las caídas desde altura son una importante causa de morbimortalidad prevenible en la edad pediátrica. Los objetivos de este estudio son describir la evolución y el pronóstico a largo plazo de los pacientes precipitados, identificar la población pediátrica con mayor riesgo de sufrir caídas desde altura en nuestro medio y definir las variables al ingreso asociadas a mortalidad. Diseño: Estudio de una cohorte retrospectivo. Ámbito: Pediatría. Participantes: Pacientes politraumatizados ingresados en el servicio de unidad de cuidados intensivos pediátricos tras haberse precipitado desde una altura superior a dos metros a lo largo de 10 años. Resultados: El 92% de las caídas se produjeron desde edificios. De 54 pacientes precipitados, el 51% fueron preescolares. En adolescentes, el intento de suicidio ha sido la causa en la mitad de los casos. Un 52% pertenece a familias inmigrantes. El traumatismo craneoencefálico fue la lesión más frecuente. La mortalidad fue del 12%. De los pacientes en los que se realizó seguimiento a los dos años, el 82% llevaban una vida independiente sin secuelas. Los factores independientes asociados a mortalidad fueron: la altura de la caída, la puntuación en la escala de coma de Glasgow y en el índice de trauma pediátrico, la anemia, la acidosis y la hipotensión al ingreso, la necesidad de drogas vasoactivas, y la presencia de TCE grave con desarrollo de hipertensión intracraneal. Conclusiones: Las caídas desde grandes alturas se producen sobre todo en preescolares sin supervisión y en adolescentes por tentativa de suicidio. Estos pacientes presentan un gran número de lesiones, una alta mortalidad y altas necesidades asistenciales. La mayoría de los supervivientes llevan una vida independiente a largo plazo. Sería necesario implantar medidas preventivas, sobre todo en la población de riesgo (AU)

Objective: Falls from heights are a major preventable cause of morbidity and mortality in children. The aims of this study are to describe the evolution and long-term prognosis of such patients, to identify the pediatric population at greatest risk of falling from heights in our setting, and to define the variables at admission capable of predicting mortality. Design: A retrospective patient cohort review was carried out. Setting: Pediatric patients. Population: Pediatric patients admitted to the pediatric intensive care unit following a fall from a height of over two meters, in the last 10 years. Results: Ninety-two percent of the patients fell from buildings. Out of a total of 54 patients suffering falls, 51% were preschoolers. Fifty percent of the adolescents cases corresponded to attempted suicide. Fifty-two percent of the children were immigrants. Head injuries were the most common type of traumatism. The mortality rate was 12%. Eighty-two percent of the patients with a follow-up period of two years were leading an independent life. The independent predictors of mortality were the height of the fall, the Glasgow coma score and pediatric trauma index score upon admission, the presence of anemia, acidosis and hypotension upon admission, the need for vasoactive drugs, and the presence of severe head injury with the development of intracranial hypertension. Conclusions: Falls from heights occur mainly in unsupervised preschool children and teenagers attempting suicide. These patients have a high number of injuries, a high mortality rate, and important care needs. Most survivors are able to lead an independent life over the long term. Preventive measures should be implemented in risk populations (AU)

[Falls from heights in Pediatrics. Epidemiology and evolution of 54 patients]. / Caídas desde grandes alturas en Pediatría. Epidemiología y evolución de 54 pacientes.

OBJECTIVE: Falls from heights are a major preventable cause of morbidity and mortality in children. The aims of this study are to describe the evolution and long-term prognosis of such patients, to identify the pediatric population at greatest risk of falling from heights in our setting, and to define the variables at admission capable of predicting mortality. DESIGN: A retrospective patient cohort review was carried out. SETTING: Pediatric patients. POPULATION: Pediatric patients admitted to the pediatric intensive care unit following a fall from a height of over two meters, in the last 10 years. RESULTS: Ninety-two percent of the patients fell from buildings. Out of a total of 54 patients suffering falls, 51% were preschoolers. Fifty percent of the adolescents cases corresponded to attempted suicide. Fifty-two percent of the children were immigrants. Head injuries were the most common type of traumatism. The mortality rate was 12%. Eighty-two percent of the patients with a follow-up period of two years were leading an independent life. The independent predictors of mortality were the height of the fall, the Glasgow coma score and pediatric trauma index score upon admission, the presence of anemia, acidosis and hypotension upon admission, the need for vasoactive drugs, and the presence of severe head injury with the development of intracranial hypertension. CONCLUSIONS: Falls from heights occur mainly in unsupervised preschool children and teenagers attempting suicide. These patients have a high number of injuries, a high mortality rate, and important care needs. Most survivors are able to lead an independent life over the long term. Preventive measures should be implemented in risk populations.

Bronquiolitis grave. Cambios epidemiológicos y de soporte respiratorio / Severe bronchiolitis. Changes in epidemiology and respiratory support

Introducción: La bronquiolitis genera muchos ingresos en las unidades de cuidados intensivos pediátricos (UCIP). Nuevas formas de soporte respiratorio podrían mejorar la asistencia de estos pacientes. Objetivo: Analizar los cambios epidemiológicos y de soporte respiratorio de los niños ingresados en la UCIP. Pacientes y métodos: Estudio observacional y retrospectivo de los pacientes ingresados por bronquiolitis en la UCIP de un hospital terciario durante la época epidémica del virus respiratorios incitial (VRS) entre los años 2005 y 2010. Resultados: Fueron ingresados 229 pacientes; el 83% estaba infectado por VRS. La media de edad fue de 1,48 meses; los menores de 3 meses generaron el mayor número de ingresos (73,3%).Diciembre fue el mes con más número de ingresos (52%). La mortalidad fue del 0,9%. La media de estancia en UCIP y de soporte respiratorio fue de 4 y 3 días (diferencias no significativas entre las diferentes epidemias). Los pacientes con bronquiolitis por VRS eran de menor edad que los VRS negativo (media 2,61 y 4,05 meses; p = 0,023). El 73% de los casos requirieron soporte respiratorio. El porcentaje de pacientes en los que se utilizó soporte respiratorio activo fue en aumentó (Z = 3,81; p = 0,00014), sobre todo a expensas de la oxigenoterapia de alto flujo con cánulas nasales (Z = 3,62; p = 0,00028). Se observó relación inversa entre la edad y los días de estancia en UCIP (beta =−0,245; p ≤ 0,0001) y de soporte respiratorio (beta =−0,167;p = 0,039).Conclusiones: La mayoría de los pacientes ingresados por bronquiolitis en la UCIP tienen menos de 3 meses. La mortalidad es del 0,9%. El soporte respiratorio (sobre todo la ventilación mecánica no invasiva y la oxigenoterapia de alto flujo en cánulas nasales) se utiliza cada vez más frecuentemente. A menor edad, más días de ingreso en UCIP y de soporte respiratorio son necesarios (AU)

Introduction: Bronchiolitis generates lots of admissions during the cold months in the paediatric intensive care units (PICU). New forms of respiratory support are being used and could improve the care of these patients. Objectives: To analyse the epidemiological and respiratory support changes of children admitted to the PICU. Patients and methods: An observational, retrospective, descriptive and analytical study of patients with the diagnosis of bronchiolitis admitted to the PICU of a tertiary hospital during the respiratory syncytial virus (RSV) epidemic months between 2005 and 2010. Results: A total of 229 patients were admitted, of whom 83% were infected with RSV. The mean age was 1.48 months, with children under 3 months being the greatest number of admissions (73.3%). December was the month with the highest number of admissions (52%). Mortality was 0.9%. The mean time of stay in the PICU and on respiratory assistance were 4 and 3 days, respectively (no significant differences between the periods studied). Patients with RSV bronchiolitis were younger than the negative RSV (mean 2.61 months and 4.05 months, P = 0.023).Active respiratory support was required in 73% of cases. The percentage of patients who required active respiratory support increased over the years (Z = 3.81, P = 0.00014), especially high flow nasal oxygen therapy (Z = 3.62, P = 0.00028). An inverse relationship was observed between patient age and length of stay in PICU (Beta =−0.245, P≤0.0001) and days on respiratory support(Beta =−0.167, P = 0.039).Conclusions: Most patients admitted to the PICU are less than 3 months old. Mortality was 0.9%. Respiratory support (especially non-invasive mechanical ventilation and high flow nasal oxygen therapy) is used increasingly often. The youngest patients need more days in PICU and more respiratory support (AU)

Síndrome de abstinencia iatrogénico en pediatría / Iatrogenic abstinence syndrome in pediatrics

No disponible

[Severe bronchiolitis. Changes in epidemiology and respiratory support]. / Bronquiolitis grave. Cambios epidemiológicos y de soporte respiratorio.

INTRODUCTION: Bronchiolitis generates lots of admissions during the cold months in the paediatric intensive care units (PICU). New forms of respiratory support are being used and could improve the care of these patients. OBJECTIVES: To analyse the epidemiological and respiratory support changes of children admitted to the PICU. PATIENTS AND METHODS: An observational, retrospective, descriptive and analytical study of patients with the diagnosis of bronchiolitis admitted to the PICU of a tertiary hospital during the respiratory syncytial virus (RSV) epidemic months between 2005 and 2010. RESULTS: A total of 229 patients were admitted, of whom 83% were infected with RSV. The mean age was 1.48 months, with children under 3 months being the greatest number of admissions (73.3%). December was the month with the highest number of admissions (52%). Mortality was 0.9%. The mean time of stay in the PICU and on respiratory assistance were 4 and 3 days, respectively (no significant differences between the periods studied). Patients with RSV bronchiolitis were younger than the negative RSV (mean 2.61 months and 4.05 months, P=.023). Active respiratory support was required in 73% of cases. The percentage of patients who required active respiratory support increased over the years (Z=3.81, P=.00014), especially high flow nasal oxygen therapy (Z=3.62, P=.00028). An inverse relationship was observed between patient age and length of stay in PICU (Beta=-0.245, P ≤.0001) and days on respiratory support (Beta=-0.167, P=.039). CONCLUSIONS: Most patients admitted to the PICU are less than 3 months old. Mortality was 0.9%. Respiratory support (especially non-invasive mechanical ventilation and high flow nasal oxygen therapy) is used increasingly often. The youngest patients need more days in PICU and more respiratory support.

Cólico del lactante: sobre lo que suele ser y lo que puede ser / Infant colic: what it usually is and what it can be

Presentamos un paciente con clínica compatible con cólico del lactante, motivadapor la presencia de vólvulo y malrotación intestinal, que asoció, además, ascitis quilosa.Describimos el ejercicio diagnóstico y el posterior tratamiento de este cuadro clínico realizando,a su vez, una breve revisión de la bibliografía disponible sobre ascitis quilosade etiología no quirúrgica (AU)

We present a case of infant colic in relation to volvulus and intestinal malrotation associatedwith chylous ascites. The experience in the diagnosis and management of this condition isrelated with a review of the literature on chilous ascites in an infant without previous surgery (AU)

Traumatismo craneoencefálico en la edad pediátrica / Cranioencephalic traumatism in the pediatric age

En los países desarrollados el traumatismo craneoencefálico (TCE) es la principal causa de muerte y de incapacidad en niños mayores de un año. Los TCE se clasifican por su gravedad, según la puntuación en la Escala de Coma de Glasgow (ECG) en leve: 14-15, moderado: 9-13 y grave: menor de 9. En las urgencias pediátricas el TCE leve es uno de los motivos más frecuentes de consulta. En el servicio de urgencias el objetivo será identificar a los pacientes con mayor riesgo de tener lesiones intracraneales graves. En el manejo del TCE moderado y grave resulta fundamental la estabilización inicial y el transporte a un centro especializado en politraumatismos en la edad pediátrica. Las medidas diagnósticas y terapéuticas específicas en pacientes con TCE grave irán destinadas a evitar el daño cerebral secundario y la hipertensión intracraneal (AU)

In the developed countries, cranioencephalc traumatism (CET) is the principal cause of death and incapacity in children over one year. CETs are classified by severity, according to the Glasgow Coma Scale (GCS) score into mild: 14-15, moderate: 9-13 and severe: less than 9. In pediatric emergencies, the mild CET is one of the most frequent reasons for the visit, In the emergency department, the objective is to identify the patients with the greatest risk of having severe intracranial lesions. In the management of moderate and severe CET, initial stabilization and transportation to a center specialized in polytraumatism in the pediatric age is fundamental. The specialized in polytraumatism in the pediatric age is fundamental. The specific diagnostic and therapeutic measures in patients with severe CET will be aimed at avoiding secondary brain damage and intracranial hypertension (AU)

[Immigration, breastfeeding and smoking habit]. / Inmigración, lactancia materna y hábito tabáquico.

OBJECTIVE: The advantages of breastfeeding for child and mother are widely recognised. Many factors seem to influence the mother's decision of breastfeed. The immigrant state of parents is one of the relevant factors considered. Previous studies founded higher breastfeeding rates among the immigrant population. The present work studies the rates of starting and duration of breastfeeding in the Spanish native population and in immigrants, as well as its relationship with other factors, such as tobacco habit and other perinatal factors. METHODS: The study included 911 children over a 10 months period. Age, sex, pregnancy duration, birth weight, parents' age, parent's smoking habits and smoking during pregnancy and their relationship the starting and duration of breastfeeding (OR and 95 % CI was obtained) in both immigrant and native population groups and a final multivariate analysis was performed for the starting of breastfeeding and continuing it at three months, including all studied variables. RESULTS: Immigrant and Native population were similar in all variables apart from mother age and smoking habit. Only mother smoking status (initial: OR 0.610 [ 0.429-0.867]; three months: OR 0.540 [0.458-0.636]) and birth weight (initial: OR 0.411 [0.268-0.629]; three months: OR 0.525 [0.407-0.677]) reached statistical significance in the final multivariate analysis. CONCLUSION: Our findings show that smoking habit and low birth weight are risk factors for not breastfeeding. Immigration status seems to be a confounding factor.

Inmigración, lactancia materna y hábito tabáquico / Immigration, breastfeeding and smoking habit

Objetivo: Los beneficios de la lactancia materna para los niños y las madres están generalmente reconocidos. Muchos factores influyen en el inicio de la lactancia materna. Entre ellos se ha señalado el estatus de inmigrantes de los padres. Algunos estudios han señalado elevadas tasas de lactancia materna entre la población inmigrante. El presente trabajo estudia la lactancia materna en población española e inmigrante, y su relación con otros factores del período neonatal. Métodos: Se han estudiado 911 niños durante un período de 10 meses, se recogieron datos sobre edad, sexo, duración del embarazo, peso al nacimiento, edad y hábito tabáquico de los padres durante el embarazo, y su relación con el inicio de lactancia materna y su duración (odds ratio [OR] e intervalo de confianza [IC] del 95 %) en los grupos de población inmigrante y autóctona, realizándose también análisis multivariante incluyendo todas las variables estudiadas. Resultados: Las variables estudiadas fueron similares entre la población autóctona y la inmigrante excepto la edad materna y el hábito tabáquico. En el análisis multivariante sólo presentaron significación estadística con la lactancia materna el hábito tabáquico de la madre (inicio: OR 0,610 [IC 95 %: 0,419-0,867]; a los 3 meses: OR 0,540 [IC 95 %: 0,458-0,636] y el peso al nacimiento < 2.500 g (inicio: OR 0,411 [IC 95 %: 0,268-0,629]; 3 meses: OR 0,525 [IC 95 %: 0,407-0,677]. Conclusión: Nuestros datos señalan que los factores de riesgo para el no inicio de la lactancia materna o su no mantenimiento a los 3 meses son el bajo peso al nacimiento y el tabaquismo materno. El ser inmigrante se ha comportado como un factor de confusión (AU)

Objective: The advantages of breastfeeding for child and mother are widely recognised. Many factors seem to influence the mother’s decision of breastfeed. The immigrant state of parents is one of the relevant factors considered. Previous studies founded higher breastfeeding rates among the immigrant population. The present work studies the rates of starting and duration of breastfeeding in the Spanish native population and in immigrants, as well as its relationship with other factors, such as tobacco habit and other perinatal factors. Methods: The study included 911 children over a 10 months period. Age, sex, pregnancy duration, birth weight, parents’ age, parent’s smoking habits and smoking during pregnancy and their relationship the starting and duration of breastfeeding (OR and 95 % CI was obtained) in both immigrant and native population groups and a final multivariate analysis was performed for the starting of breastfeeding and continuing it at three months, including all studied variables. Results: Immigrant and Native population were similar in all variables apart from mother age and smoking habit. Only mother smoking status (initial: OR 0.610 [ 0.429-0.867]; three months: OR 0.540 [0.458-0.636]) and birth weight (initial: OR 0.411 [0.268-0.629]; three months: OR 0.525 [0.407-0.677]) reached statistical significance in the final multivariate analysis. Conclusion: Our findings show that smoking habit and low birth weight are risk factors for not breastfeeding. Immigration status seems to be a confounding factor (AU)