Abuso sexual infantil: desafío multidisciplinar. Un abordaje integral del problema para mejorar su detección y la atención a la víctima / Child sexual abuse, a multidisciplinary challenge: an integral approach to the problem to improve its detection and victim care

El abuso sexual infantil (ASI) es el delito de malos tratos a menores que más sumergida y silenciosamente ocurre ante la sociedad, por lo que en un alto porcentaje queda impune. Las secuelas que origina en la psicología de la víctima son profundas y prolongadas, y a menudo resultan devastadoras para su biografía posterior, hecho que sólo puede ser evitado si el abuso es detectado y se brinda al menor una adecuada rehabilitación psicoemocional. La mejora en su detección y abordaje profesional es una responsabilidad que recae, entre otros servidores públicos, sobre el pediatra. Pero el análisis objetivo de este problema pone de manifiesto que las formas más comunes de presentación clínica del ASI ante el pediatra son las crípticas, sobre todo en forma de trastornos comportamentales o de somatizaciones neuróticas de la víctima, a priori inespecíficas, por efecto del desbordamiento emocional debido al padecimiento silencioso y a la vivencia solitaria de desamparo, en la mayoría de los casos, sin mediar revelación alguna por parte de aquélla ni hallar pruebas físicas en su exploración. Ante este hecho, y partiendo sólo de una mera sospecha o posibilidad intuida, el pediatra se enfrenta a un auténtico desafío en su deber de detección, asistencia, notificación y custodia a la víctima. El presente trabajo tiene por objetivo ayudar al pediatra a orientar correctamente su actuación al afrontar este desafío. Se expone para ello el resultado de un análisis integral del problema, en el que han sido abordados no sólo aspectos de la presentación clínica y la actuación médica a recomendar, sino también de la fenomenología social y familiar del ASI y del devenir judicial y biográfico de los casos, con el fin de orientar mejor la actuación pediátrica. Ésta, que debe tener como objetivo prioritario la protección y rehabilitación emocional del menor, pero intentando minimizar al máximo las posibles repercusiones psicosociales en la víctima y su familia, no halla su única solución en el aumento de formación y concienciación pediátricas, sino que exige la habilitación de recursos especializados y multidisciplinares, ágiles, discretos y capaces de asumir un seguimiento coordinado a largo plazo, lamentablemente aún no disponibles en muchas comunidades de nuestro país. Este tipo de seguimiento multidisciplinar y coordinado, necesario también para otras formas de sospecha de maltrato y patologías de índole psicosocial, es justificación suficiente para reivindicar la creación de Unidades de Pediatría Psicosocial (AU)

Child Sexual Abuse (CSA) is the crime of child abuse that occurs so stealthily and is so submerged in society that it often goes unpunished. The psychological sequels for the victim are both deep and prolonged and can lead to devastating effects on the child's future which can only be prevented if the abuse is detected and appropriate psychoemotional rehabilitation rovided. The improvement of its detection and victim treatment is a professional sponsibility that lies on the pediatrician, along with other public servants. However, an objective analysis of this issue makes it evident that most common forms of clinical presentation of CSA to the paediatrician are cryptic and usually present themselves as behavioral disorders or neurotic somatization of the victim, a priori unspecified, as consequence of the emotional overflow caused by suffering in silence and solitary experience of helplessness, in the majority of cases, without any disclosure on the victim's part or the finding of any physical evidence after our exploration. Given this fact, the pediatrician is faced with the challenging task of detecting, assisting, reporting and taking care of the victim on the basis of mere suspicion or intuition. The present work aims to help the pediatrician to correctly guide their actions to meet this challenge. A comprehensive analysis of the problem is carried out, addressing not only aspects of the clinical and medical action to recommend, but also the social and family phenomenology of CSA and the legal and biographical becoming of cases, in order to target the pediatric performance. This, it must have as a priority the child's emotional protection and rehabilitation, but trying to minimize the maximum the possible sychosocial impact on the victim and his family. To achieve this it's not the only solution in increasing pediatric training and awareness, but requires the empowerment of specialized resources for a multidisciplinary assessment which has to be prompt, discreet and capable of providing long-term follow up, not yet available in many communities in our country. The need for this multidisciplinary and coordinated monitoring, which is also required in other types of abuse and psycho-social pathologies, is reason enough to vindicate the creation of Pediatric Psycho-Social Units (AU)

[Management of agitated, violent or psychotic patients in the emergency department: an overdue protocol for an increasing problem]. / Atención al paciente agitado, violento o psicótico en urgencias: un protocolo pendiente para una patología en aumento.

Patients with extreme agitation, delirium, violent behavior or acute psychosis are frequently evaluated in the emergency departments of general hospitals. However, the traditional infrequency of this type of situation in pediatric emergency services can lead to a certain lack of foresight and efficiency in the initial management of these patients. Because of the current known increase of psychosocial disorders in pediatric emergencies, new pharmacological treatments for juvenile psychotic processes, and particularly the lack of compliance with these treatments, as well as the earlier consumption of ever more varied illicit drugs among young people, the frequency and diversity of this kind of disorder is on the increase. The treatment of agitation, aggression and violence begins with successful management of the acute episode, followed by strategies designed to reduce the intensity and frequency of subsequent episodes. The key to safety is early intervention to prevent progression from agitation to aggression and violence. Consequently, urgent measures designed to inhibit agitation should be adopted without delay by the staff initially dealing with the patient, usually in the emergency unit. Patients with psychomotor agitation disorder (PMAD) may require emergency physical and/or chemical restraints for their own safety and that of the healthcare provider in order to prevent harmful clinical sequelae and to expedite medical evaluation to determine the cause. However, the risks of restraint measures must be weighed against the benefits in each case. This review aims to present the emergency measures to be taken in children with PMAD. The distinct etiological situations and criteria for the choice of drugs for chemical restraint in each situation, as well as the complications associated with certain drugs, are discussed. It is advisable, therefore, that health professionals become familiar with the distinct pharmacological options.

Atención al paciente agitado, violente o psicótico en urgencias: un protocolo pendiente para una patología en aumento / Management of agited, violent or psychotic patients in the emergency department: an overdue protocol for an increasing problem

El paciente con extrema agitación, delirio, comportamiento violento o psicosis aguda es un problema de evaluación frecuente en la sala de urgencias de un hospital general. En cambio, en los servicios de urgencias pediátricas, la tradicional infrecuencia de este tipo de cuadros puede conducir a un cierto grado de imprevisión e ineficiencia en la atención inicial a estos casos. El actual incremento conocido de la patología de origen psicosocial en las urgencias pediátricas, las nuevas terapias medicamentosas de los procesos psicóticos juveniles y, más en particular su incumplimiento, así como la aproximación más temprana de nuestros jóvenes al consumo de sustancias adictivas, cada vez más variadas, nos enfrentan a un aumento en la frecuencia y la diversidad de este tipo de crisis. El tratamiento de la agitación, agresión y/o violencia empieza con el tratamiento exitoso del episodio agudo, seguido por estrategias destinadas a reducir la intensidad y frecuencia de los episodios subsiguientes. La clave para la seguridad es intervenir precozmente con objeto de prevenir la progresión de la agitación a agresión y violencia. Por eso, las medidas urgentes, destinadas a inhibir la agitación, deben ser adoptadas sin demora por el personal que atiende primero al paciente, y que suele ser en las unidades de urgencias. Los pacientes en crisis de agitación psicomotriz (CAPM) pueden requerir medidas urgentes de contención física y/o química, para asegurar su propia integridad, la seguridad de sus cuidadores sanitarios, prevenir secuelas clínicas graves y permitir su evaluación clínica para determinar la etiología. Pero los riesgos derivados de las medidas de contención deben conocerse y ser sopesados frente a los beneficios en cada caso. El propósito de este artículo es exponer la actuación urgente que se debe seguir ante un niño con CAPM, intentando definir las distintas situaciones etiológicas y los criterios de elección de medicamentos para el control químico en cada una de ellas, así como advertir de las complicaciones asociadas a los agentes medicamentosos que emplear y de la conveniencia, por tanto, de que los profesionales se familiaricen con las distintas opciones farmacológicas

Patients with extreme agitation, delirium, violent behavior or acute psychosis are frequently evaluated in the emergency departments of general hospitals. However, the traditional infrequency of this type of situation in pediatric emergency services can lead to a certain lack of foresight and efficiency in the initial management of these patients. Because of the current known increase of psychosocial disorders in pediatric emergencies, new pharmacological treatments for juvenile psychotic processes, and particularly the lack of compliance with these treatments, as well as the earlier consumption of ever more varied illicit drugs among young people, the frequency and diversity of this kind of disorder is on the increase. The treatment of agitation, aggression and violence begins with successful management of the acute episode, followed by strategies designed to reduce the intensity and frequency of subsequent episodes. The key to safety is early intervention to prevent progression from agitation to aggression and violence. Consequently, urgent measures designed to inhibit agitation should be adopted without delay by the staff initially dealing with the patient, usually in the emergency unit. Patients with psychomotor agitation disorder (PMAD) may require emergency physical and/or chemical restraints for their own safety and that of the healthcare provider in order to prevent harmful clinical sequelae and to expedite medical evaluation to determine the cause. However, the risks of restraint measures must be weighed against the benefits in each case. This review aims to present the emergency measures to be taken in children with PMAD. The distinct etiological situations and criteria for the choice of drugs for chemical restraint in each situation, as well as the complications associated with certain drugs, are discussed. It is advisable, therefore, that health professionals become familiar with the distinct pharmacological options

[Acute purulent pericarditis in childhood]. / Pericarditis purulenta aguda en la infancia.

Four children with acute purulent pericarditis were seen at the Children's Hospital "La Fe", Valencia, between 1980 and 1985. Their ages ranged between 7 months and 7 years. All patients had some other associated infection, such as pneumonia (1 case), pyodermitis (1 case) and sepsis (2 cases). Pathogens identified were Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae and Neisseria meningitidis. M-mode echocardiography and 2-dimensional echocardiography has proven to be a reliable tool in diagnosis of pericardial effusions. A 2-dimensional echocardiogram is indicated when a loculated pericardial effusions is suspected (Staphylococcus aureus pericarditis). Pericardiocentesis alone resulted in recovery of three patients and failed in one (Staphylococcus aureus pericarditis). This one was treated with pericardiectomy and recovered without complications.