[Knowledge of health care ethics in paediatric residents]. / Conocimientos sobre ética asistencial de los residentes de pediatría.

INTRODUCTION: Bioethics has been recently incorporated in to the educational programs of both medical students and medical residents as part of their curriculum. However, its training based on clinical practice is not well structured. OBJECTIVE: To evaluate the knowledge of bioethics in Spanish paediatric residents, and to analyse how this relates to the medical education during graduate and post-graduate training. MATERIAL AND METHODS: A questionnaire with 20 multiple choice questions was designed to evaluate the knowledge in basic ethics with potential implications in clinical practice. We evaluated the education received during graduate and post-graduate training, and the main ethical conflicts faced. RESULTS: A total of 210 completed questionnaires were received from medical residents in paediatrics from 20 different Spanish hospitals, of whom 47 of these were first year residents (R1), 49 were second year residents (R2), 57 were third year residents (R3), and the remaining 57 were final year residents (R4). The mean number of correct answers was 16.8 out of 20. No differences were found between residents in different years of training, nor were there any differences between the group that had received specific training in bioethics versus those who had not. Residents were more likely to give wrong answers related with informed consent, the law on the freedom of the patient, principles of quality of life, the case analysis system, and the dimension of distributive justice. CONCLUSIONS: Limitation of therapeutic efforts was identified as the main ethical problem faced in clinical practice by Spanish residents in paediatrics. Most of the knowledge of bioethics is acquired during graduate training, and improved very little throughout the period of medical residence. Our results suggest that efforts are required in organising and structuring the education in bioethics during the training of residents in paediatrics.

Fiebre, astenia, mialgia y soplo por mixoma cardíaco / Fever, asthenia, myalgia and murmur due to cardiac myxoma

Los tumores cardíacos son infrecuentes, sobre todo en la edad pediátrica, y en su mayoría son benignos. Los mixomas son excepcionales en pediatría, aunque son los más frecuentes en el adulto. La mayoría se encuentra en la aurícula izquierda, presentándose en un 25% en la derecha. Su cuadro clínico depende principalmente de la ubicación del tumor. Una característica de estos tumores es que se pueden acompañar de clínica sistémica y de alteraciones analíticas. La ecocardiografía es el estudio de elección y debe realizarse su resección temprana para evitar complicaciones graves. Se presenta el caso de una niña de 10 años diagnosticada de un mixoma auricular derecho a partir de una clínica de fiebre, mialgias, astenia y alteraciones analíticas. Se llega al diagnóstico mediante ecocardiografía; se realiza la exéresis de la tumoración sin incidencias y presenta buena evolución posquirúrgica (AU)

Cardiac tumours are rare, especially in children, and most of them are benign. Myxomas are unusual in children, being more common among adults. They are usually located in the left atrium, with 25% appearing in the right. The clinical signs and symptoms depend mainly on where the tumour is located. A feature of these tumours is that they can be accompanied by constitutional symptoms and laboratory abnormalities. Echocardiography is the study of choice, and a prompt resection is required to prevent serious complications. We present a case of a 10 year-old girl diagnosed with right atrial myxoma who presented with a fever, myalgia, asthenia and laboratory abnormalities. Diagnosis was made by echocardiography, and the early surgical resection of the tumour ran smoothly and showed a good postoperative recovery (AU)

[Fever, asthenia, myalgia and murmur due to cardiac myxoma]. / Fiebre, astenia, mialgia y soplo por mixoma cardíaco.

Cardiac tumours are rare, especially in children, and most of them are benign. Myxomas are unusual in children, being more common among adults. They are usually located in the left atrium, with 25% appearing in the right. The clinical signs and symptoms depend mainly on where the tumour is located. A feature of these tumours is that they can be accompanied by constitutional symptoms and laboratory abnormalities. Echocardiography is the study of choice, and a prompt resection is required to prevent serious complications. We present a case of a 10 year-old girl diagnosed with right atrial myxoma who presented with a fever, myalgia, asthenia and laboratory abnormalities. Diagnosis was made by echocardiography, and the early surgical resection of the tumour ran smoothly and showed a good postoperative recovery.

[Pediatric intensive care after brain tumor surgery]. / Postoperatorio de tumores cerebrales en la unidad de cuidados intensivos pediátricos.

INTRODUCTION: Primary brain tumors are the most common solid tumors in children. Surgery is the basis of treatment for these patients, who require postoperative admission to the ICU-P. The aim of this study was to at the epidemiology of brain tumors of patients admitted to our ICU-P and to analyze the progress of these children in the postoperative period. PATIENTS AND METHODS: Retrospective-prospective study of children admitted to our unit after brain tumor surgery between January 1998 and January 2007. We collected information such as, personal details, clinical characteristics, type of intervention and postoperative period. RESULTS: We reviewed 161 postoperative periods, corresponding to 134 patients (54.5% male). The mean age was 7 years and 8 months +/- 5 months. The most common location was the posterior fossa (44.8%). The most common histological type was low grade/intermediate astrocytoma (44.7%). The most frequent complication was diabetes insipidus (9.9%). Resection was complete in 58.4% patients. The median stay in the ICU-P was 2 days (0-61 days). 3 patients died after surgery. CONCLUSIONS: The epidemiology of the group of patients admitted to our ICU-P is similar to the general population. The most common complication is diabetes insipidus.

Postoperatorio de tumores cerebrales en la unidad de cuidados intensivos pediátricos / Pediatric intensive care after brain tumor surgery

Introducción: Los tumores primarios cerebrales son la neoplasia sólida más frecuente en la infancia. La base fundamental del tratamiento de estos pacientes es la cirugía, cuyo postoperatorio requiere ingreso en la unidad de cuidados intensivos pediátricos (UCIP). Los objetivos de nuestro trabajo son: conocer la epidemiología de los tumores que ingresan en nuestra unidad y analizar el postoperatorio de estos niños. Pacientes y métodos: Estudio prospectivo y retrospectivo de todos los niños intervenidos de tumor cerebral desde enero de 1998 hasta enero de 2007 en nuestro hospital. Se recogen datos referentes a filiación, características clínicas, tipo de intervención y postoperatorio. Resultados: Se revisan 161 postoperatorios, correspondientes a 134 pacientes (el 54,5%, varones). La media ± desviación estándar de edad es 7 años y 8 meses ± 5 meses. La localización más frecuente es la fosa posterior (44,8%). El tipo histológico principal es el astrocitoma de grado bajo/intermedio (44,7%). La complicación más frecuente es la diabetes insípida (9,9%). La resección es total en el 58,4% de los pacientes. La mediana de estancia en UCIP es de 2 días (0-61 días). Fallecieron 3 pacientes tras la intervención. Conclusiones: La epidemiología del grupo de pacientes que llega a UCIP es similar a la población general. La complicación más frecuente es la diabetes insípida (AU)

Introduction: Primary brain tumors are the most common solid tumors in children. Surgery is the basis of treatment for these patients, who require postoperative admission to the ICU-P. The aim of this study was to at the epidemiology of brain tumors of patients admitted to our ICU-P and to analyze the progress of these children in the postoperative period. Patients and methods: Retrospective-prospective study of children admitted to our unit after brain tumor surgery between January 1998 and January 2007. We collected information such as, personal details, clinical characteristics, type of intervention and postoperative period. Results: We reviewed 161 postoperative periods, corresponding to 134 patients (54.5% male). The mean age was 7 years and 8 months±5 months. The most common location was the posterior fossa (44.8%). The most common histological type was low grade/intermediate astrocytoma (44.7%). The most frequent complication was diabetes insipidus (9.9%). Resection was complete in 58.4% patients. The median stay in the ICU-P was 2 days (0–61 days). 3 patients died after surgery .Conclusions: The epidemiology of the group of patients admitted to our ICU-P is similar to the general population. The most common complication is diabetes insipidus (AU)

[Glossary of bioethic terms and expressions frequently used in pediatric intensive care practice]. / Glosario de términos y expresiones frecuentes de bioética en la práctica de cuidados intensivos pediátricos.

Ethical issues are of increasing interest in current medicine, and pediatrics is no exception. In critical care, the relevance of these considerations becomes even greater. Commonly used expressions in bioethics, frequently lead to terminological confusion and misunderstandings, as reported by several publications, revealing a lack of clear concepts in many cases. As an attempt to clarify or facilitate the comprehension of the most relevant terms in this field, the Spanish Society of Pediatric Intensive Care has prepared a Glossary of the most commonly used terms and expressions.

[Fluid and electrolyte disorders following surgery for brain tumors]. / Trastornos hidroelectrolíticos en postoperados de tumores cerebrales.

INTRODUCTION: Fluid and electrolyte disorders such as diabetes insipidus, salt wasting syndrome (SWS) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) can appear in the immediate postoperative period after surgery for brain tumors. Early diagnosis and treatment are important to prevent the potential adverse effects of these disorders on the central nervous system (CNS). OBJECTIVES: To determine the incidence and characteristics of fluid and electrolyte disorders in the immediate postoperative period after surgery for CNS tumors in children treated in our hospital. MATERIAL AND METHODS: We retrospectively analyzed clinical and laboratory data in all infants and children who underwent surgery for CNS tumors in our hospital from January 1998 to June 2005 and who met the laboratory criteria for diabetes insipidus, SWS or SIADH. RESULTS: Twenty-three electrolyte disorders were identified in 149 surgical patients (an incidence of 15.4%). The median age was 5 years and 3 months (from 6 months to 17 years) and 48.7% of the patients were male. The most frequent electrolyte disturbance was diabetes insipidus (65.2% of all electrolyte disorders). On average, onset of diabetes insipidus occurred 19 hours after surgery. Treatment with desmopressin was administrated in all patients. On average, diabetes insipidus was resolved 73 hours after diagnosis, except in one patient with permanent diabetes insipidus due to a surgical lesion of the hypothalamic-pituitary axis. The second most frequent electrolyte disturbance was SWS (26.1%) with a mean time of onset of 50.4 hours after surgery. On average, SWS was resolved 57.6 hours after administration of saline solutions. Only two patients developed SIADH, which was treated with water restriction and adequate sodium supply. Both cases of SIADH resolved spontaneously in the first 36 hours after diagnosis. At discharge, none of the patients showed neurological disturbances due to an electrolytic disorder. CONCLUSIONS: In our series, the most frequent electrolyte disorder after surgery for CNS tumors was diabetes insipidus. Early treatment with desmopressin almost always prevents hypernatremia. Unless there is a surgical lesion of the hypothalamic-pituitary axis, spontaneous resolution will take place in 3 days on average. The management of SWS and SIADH requires close monitoring of plasma sodium due to the risk of hyponatremia.

Trastornos hidroelectrolíticos en postoperados de tumores cerebrales / Fluid and electrolyte disorders following surgery for brain tumors

Introducción Entre las complicaciones que pueden aparecer en el postoperatorio inmediato de los tumores cerebrales destacan los trastornos hidroelectrolíticos (diabetes insípida, síndrome pierde sal y síndrome de secreción inadecuada de hormona antidiurética [SIADH]). Es importante su diagnóstico y tratamiento precoz de cara a prevenir los posibles efectos negativos que pueden tener sobre el propio sistema nervioso central (SNC). Objetivos Valorar la incidencia y características de los trastornos electrolíticos aparecidos en el postoperatorio inmediato de los niños intervenidos de tumores del SNC en nuestro centro. Material y métodos Análisis retrospectivo de las historias clínicas de niños intervenidos de tumores del SNC en nuestro centro entre enero de 1998 y junio de 2005, que en el postoperatorio cumplieron criterios analíticos de diabetes insípida, síndrome pierde sal o SIADH. Resultados Se detectaron 23 trastornos hidroelectrolíticos en 149 intervenciones (15,4 %). El 47,8 % fueron varones. La mediana de edad fue de 5 años y 3 meses (rango de 6 meses a 17 años). La alteración electrolítica más frecuente fue diabetes insípida (65,2 %). El trastorno apareció en una media de 19 h tras la cirugía. Se administró desmopresina en todos los casos, con resolución del cuadro en una media de 73 h tras el diagnóstico, excepto un caso de diabetes insípida permanente por lesión quirúrgica del eje hipotálamo- hipofisario. El síndrome pierde sal, con un 26,1 % de los casos, fue el segundo trastorno hidroelectrolítico en frecuencia. El tiempo medio de aparición tras la cirugía fue de 50,4 h. Se adecuó el aporte hidrosalino en todos los casos. El trastorno se resolvió en una media de 57,6 h tras su aparición. Sólo se detectaron 2 casos de SIADH que se trataron con restricción hídrica y adecuación de aportes de sodio. Ambos casos se resolvieron espontáneamente en las primeras 36 h tras el diagnóstico. Al alta ningún paciente presentaba alteraciones neurológicas secundarias al trastorno hidroelectrolítico. Conclusiones El trastorno hidroelectrolítico más frecuente en postoperados de tumores cerebrales en nuestra serie ha sido la diabetes insípida. El tratamiento precoz con desmopresina evita en la mayor parte de los casos la aparición de hipernatremia. Si no existe lesión quirúrgica del eje hipotálamo- hipofisario la resolución espontánea se produce en una media de 3 días. El manejo del síndrome pierde sal y el SIADH requiere una estrecha monitorización del sodio plasmático por la gran tendencia a la hiponatremia

Introduction Fluid and electrolyte disorders such as diabetes insipidus, salt wasting syndrome (SWS) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) can appear in the immediate postoperative period after surgery for brain tumors. Early diagnosis and treatment are important to prevent the potential adverse effects of these disorders on the central nervous system (CNS). Objectives To determine the incidence and characteristics of fluid and electrolyte disorders in the immediate postoperative period after surgery for CNS tumors in children treated in our hospital. Material and methods We retrospectively analyzed clinical and laboratory data in all infants and children who underwent surgery for CNS tumors in our hospital from January 1998 to June 2005 and who met the laboratory criteria for diabetes insipidus, SWS or SIADH. Results Twenty-three electrolyte disorders were identified in 149 surgical patients (an incidence of 15.4 %). The median age was 5 years and 3 months (from 6 months to 17 years) and 48.7 % of the patients were male. The most frequent electrolyte disturbance was diabetes insipidus (65.2 % of all electrolyte disorders). On average, onset of diabetes insipidus occurred 19 hours after surgery. Treatment with desmopressin was administrated in all patients. On average, diabetes insipidus was resolved 73 hours after diagnosis, except in one patient with permanent diabetes insipidus due to a surgical lesion of the hypothalamic-pituitary axis. The second most frequent electrolyte disturbance was SWS (26.1 %) with a mean time of onset of 50.4 hours after surgery. On average, SWS was resolved 57.6 hours after administration of saline solutions. Only two patients developed SIADH, which was treated with water restriction and adequate sodium supply. Both cases of SIADH resolved spontaneously in the first 36 hours after diagnosis. At discharge, none of the patients showed neurological disturbances due to an electrolytic disorder. Conclusions In our series, the most frequent electrolyte disorder after surgery for CNS tumors was diabetes insipidus. Early treatment with desmopressin almost always prevents hypernatremia. Unless there is a surgical lesion of the hypothalamic- pituitary axis, spontaneous resolution will take place in 3 days on average. The management of SWS and SIADH requires close monitoring of plasma sodium due to the risk of hyponatremia

[Supraventricular tachycardia in infants and children]. / Taquicardia paroxística supraventricular en el niño y el lactante.

INTRODUCTION: Supraventricular tachycardia (SVT) is the second most frequent form of arrhythmia in pediatrics after extrasystole. OBJECTIVES: 1. To determine the clinical characteristics and treatment of SVT in infants and children. 2. To determine treatment response and the drugs used. METHOD: A retrospective review of 61 cases of SVT requiring PICU admission (1999-2004) was performed. PICU admission was due to persistent SVT after vagal maneuvers. RESULTS: There were 61 patients and 39 were boys (63.9%). The mean age was 2.1 years (SD +/- 3.1). Twelve patients had congenital heart disease (19.7%); three (4.9%) were admitted after heart surgery, and the remaining patients had no antecedents (60.7%). The mean cardiac frequency was 238 beats/min (SD +/- 42.86). Heart failure (HF) was observed in 14 patients (23%). Statistically significant differences were found between the presence of HF and time since onset (p < 0.01) and younger age (p < 0.01). The most frequent diagnosis was SVT due to re-entry in 28 patients (45.9%). Medical treatment was required in 46 patients (75.4%) and response was achieved in 35 (57.4%). At crisis the first drug used was adenosine triphosphate (ATP) in 35 patients (61.4%) with good response in 21 (36.8%). As maintenance therapy digoxin was used in 29 patients (50.9%) without relapses in 22 (78.6%). Radiofrequency ablation was required in 17 patients (27.9%), and there were three relapses (17.6%). The ages of patients who underwent ablation ranged from 3.5 days to 13 years. CONCLUSIONS: 1. HF was observed mainly in infants. 2. Most of the patients had good response to ATP therapy. 3. Radiofrequency ablation was mainly required in patients aged more than 1 year.

[Management of pediatric multiple trauma patients. Perspective of the pediatric intensive care unit]. / Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos.

OBJECTIVE: To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). MATERIAL AND METHODS: A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. RESULTS: Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. CONCLUSION: In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

Taquicardia paroxística supraventricular en el niño y el lactante / Supraventricular tachycardia in infants and children

Introducción La taquicardia paroxística supraventricular (TPSV) es la arritmia más frecuente en pediatría por detrás de las extrasístoles. Objetivos 1. Determinar las características clínicas y el tratamiento. 2. Objetivar la respuesta al tratamiento y los fármacos utilizados. Método Estudio retrospectivo de 61 casos con ingreso en la unidad de cuidados intensivos pediátrica (UCIP) de 1999 a 2004. Criterio de ingreso: TPSV sin respuesta a maniobras vagales. Resultados Se seleccionaron 61 pacientes, 39 varones (63,9 %). Edad media: 2,1 años (DE ± 3,1). Doce tuvieron antecedentes de cardiopatía congénita (19,7 %); tres (4,9 %) ingresaron poscirugía cardíaca; y los restantes sin antecedentes (60,7 %). La frecuencia cardíaca media fue de 238 lat./min (DE ± 42,86). Catorce pacientes (23 %) presentaron insuficiencia cardíaca (IC). Existieron diferencias estadísticamente significativas entre la presencia de IC y las horas de evolución (p < 0,01) y con la menor edad (p < 0,01). El diagnóstico más frecuente fue TPSV por reentrada (28 casos 45,9 %). Precisaron tratamiento médico 46 pacientes (75,4 %), 35 respondieron (57,4 %). Para tratar la crisis aguda se utilizó trifosfato de adenosina (ATP) en 35 casos (76 %) con buena respuesta en 21 (60 %). Para el mantenimiento se indicó digital en 29 casos (50,9 %), sin recaídas 22 casos (78,6 %). Necesitaron ablación 17 pacientes (27,9 %); recayeron tres (17,6 %). El rango de edades en los que se realizó la ablación fue de 3,5 días hasta 13 años. Conclusiones 1. La insuficiencia cardíaca se presentó preferentemente en lactantes. 2. La mayoría de pacientes respondieron al tratamiento con ATP. 3. La ablación fue necesaria preferentemente en pacientes de edad superior a un año

Introduction Supraventricular tachycardia (SVT) is the second most frequent form of arrhythmia in pediatrics after extrasystole. Objectives 1. To determine the clinical characteristics and treatment of SVT in infants and children. 2. To determine treatment response and the drugs used. Method A retrospective review of 61 cases of SVT requiring PICU admission (1999-2004) was performed. PICU admission was due to persistent SVT after vagal maneuvers. Results There were 61 patients and 39 were boys (63.9 %). The mean age was 2.1 years (SD ± 3.1). Twelve patients had congenital heart disease (19.7 %); three (4.9 %) were admitted after heart surgery, and the remaining patients had no antecedents (60.7 %). The mean cardiac frequency was 238 beats/min (SD ± 42.86). Heart failure (HF) was observed in 14 patients (23 %). Statistically significant differences were found between the presence of HF and time since onset (p < 0.01) and younger age (p < 0.01). The most frequent diagnosis was SVT due to re-entry in 28 patients (45.9 %). Medical treatment was required in 46 patients (75.4 %) and response was achieved in 35 (57.4 %). At crisis the first drug used was adenosine triphosphate (ATP) in 35 patients (61.4 %) with good response in 21 (36.8 %). As maintenance therapy digoxin was used in 29 patients (50.9 %) without relapses in 22 (78.6 %). Radiofrequency ablation was required in 17 patients (27.9 %), and there were three relapses (17.6 %). The ages of patients who underwent ablation ranged from 3.5 days to 13 years. Conclusions 1. HF was observed mainly in infants. 2. Most of the patients had good response to ATP therapy. 3. Radiofrequency ablation was mainly required in patients aged more than 1 year

Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos / Management of pediatric multiple trauma patients. Perspective of the pediatricintensive care unit

Objetivos Conocer la realidad de la asistencia a los pacientes traumáticos en España. Material métodos Se parte de los resultados de una encuesta a las 43 unidades de cuidados intensivos pediátricos (UCIP) acreditadas. Se preguntaba sobre la existencia de protocolos, programas y registro de traumáticos, quién era el responsable, si se impartían cursos de formación, la casuística, la edad y sus recursos humanos y materiales. Resultados Contestaron 24 unidades. En el 66 % el intensivista es el responsable de la asistencia, el 59 % no dispone de cursos de formación y el 62 % registro de trauma. Los pacientes traumáticos representaron como media el 11 % del total de ingresos y la edad comprendía mayoritariamente hasta los 14 años. El anestesista realiza guardias de presencia física en el 100 %, el radiólogo y traumatólogo en el 91 % y el neurocirujano en el 66 %. El cirujano pediátrico en el 50 %. El resto de especialidades quirúrgicas y médicas están mayoritariamente de guardia localizada. El 87 % tiene registro de presión intracraneal, el 54 % saturación de la yugular, el 50 % electroencefalograma continuo y ecografía Doppler transcraneal las 24 h. El 100 % dispone de tomografía computarizada y ecografía las 24 h, resonancia magnética ecocardiografía en el 44 % y arteriografía en el 42 %. Conclusión Se deduce que en España se ha optado por desarrollar equipos pediátricos en el marco de hospitales generales y liderados por el intensivista pediátrico. Se observa en algunos centros una carencia de recursos técnicos y materiales por lo que cabría definir cuáles son los mínimos imprescindibles para acreditar un hospital como receptor de niños traumáticos. Se aprecia una falta de programas de formación en esta materia que debería llevar a organizar cursos en este sentido

Objective To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). Material and methods A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. Results Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66 % of the hospitals. No training courses were available in 59 % of the hospitals. No trauma register was available in 62 % of the hospitals. Trauma patients represented 11 % of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100 % of the hospitals. A radiologist and traumatologist were always at the hospital in 91 %, a neurosurgeon in 66 % and a pediatric surgeon in 50 %. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87 % of the PICUs, jugular venous saturation monitoring in 54 % and continuous electroencephalogram and transcranial Doppler ultrasound in 50 %. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44 % of the hospitals, and arteriography in 42%. Conclusion In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required

[Seat belt syndrome. Acute spinal cord injury due to incorrect use of two-point seat belts]. / Síndrome del cinturón de seguridad: lesión medular aguda por uso incorrecto del cinturón de seguridad de dos puntos.

Traumatic spinal cord injury (SCI) is a rare entity in the pediatric age group. These injuries are mainly caused by road traffic accidents (RTA), especially in children not wearing a seat belt. The use of child safety devices such as seat belt restraints has decreased morbidity and mortality in RTA but their incorrect use can also produce serious injuries that are grouped under the term "seat-belt syndrome". This syndrome associates vertebral and spinal cord injuries, intra-abdominal, cutaneous, and muscle-skeletal lesions. We present three patients with complete spinal cord and intra-abdominal injuries, requiring urgent surgery in two of them. On examination, all three patients had seat belt marks on the lower abdominal region. The three patients can be included in this syndrome and its main cause was the use of a two-point seat belt.

Síndrome del cinturón de seguridad: lesión medular aguda por uso incorrecto del cinturón de seguridad de dos puntos / Seat belt syndrome. Acute spinal cord injury due to incorrect use of two-point seat belts

Las lesiones medulares traumáticas son entidades poco frecuentes en la edad pediátrica. La principal causa son los accidentes de tráfico y se dan generalmente en pacientes no portadores del cinturón de seguridad. El uso de los dispositivos de seguridad, como el cinturón, ha disminuido la morbimortalidad en los accidentes, pero el uso incorrecto puede también producir lesiones graves que se describen dentro del denominado síndrome del cinturón de seguridad (seat-belt syndrome). Este síndrome asocia la presencia de lesiones vertebrales, medulares, de vísceras abdominales sólidas y/o huecas y lesiones musculoesqueléticas y cutáneas. Presentamos 3 casos clínicos de pacientes con lesiones medulares completas y lesiones intraabdominales, requiriendo cirugía urgente en dos de ellos. Destaca la presencia en todos ellos de la marca del cinturón de seguridad a nivel abdominal. Los 3 casos pueden ser incluidos en este síndrome y su principal causa es la utilización del cinturón con banda abdominal de 2 puntos

Traumatic spinal cord injury (SCI) is a rare entity in the pediatric age group. These injuries are mainly caused by road traffic accidents (RTA), especially in children not wearing a seat belt. The use of child safety devices such as seat belt restraints has decreased morbidity and mortality in RTA but their incorrect use can also produce serious injuries that are grouped under the term 'seat-belt syndrome'. This syndrome associates vertebral and spinal cord injuries, intra-abdominal, cutaneous, and muscle-skeletal lesions. We present three patients with complete spinal cord and intra-abdominal injuries, requiring urgent surgery in two of them. On examination, all three patients had seat belt marks on the lower abdominal region. The three patients can be included in this syndrome and its main cause was the use of a two-point seat belt

[Ethical attitudes in Spanish pediatric critical care units]. / Encuesta de ética en las unidades de cuidados intensivos pediátricos españolas.

OBJECTIVES: To assess physicians' awareness and experience of ethical problems that arise when dealing with critically ill children in pediatric intensive care units (PICUs). MATERIAL AND METHODS: Questionnaires containing 20 questions about ethical dilemmas and attitudes related to the care of children admitted to PICUs were mailed to 43 PICUs in Spain. RESULTS: Ninety-five responses corresponding to 24 residents and 71 attending physicians were received from 21 PICUs. The occurrence of ethical dilemmas in the PICU was recognized by 96.8 % of the respondents. The most frequent method of solving these problems was through medical consensus (80 %), while family participation in the decision making process was highly variable. A total of 95.8 % of respondents stated that decisions to limit therapy were made in their PICU, although only one third of these decisions were written in the medical record. The most frequent form of therapeutic limitation was the do not resuscitate order. One third (32.6 %) of participants considered there were ethical differences between withdrawal and withholding of treatment. Attending physicians had greater experience of therapeutic limitation than did residents, but their opinions on the subject were similar. CONCLUSIONS: Ethical dilemmas are common in the PICU. In this setting, decisions about limitation of therapy are frequent, although many physicians admit to not being clear on this issue or on other aspects of clinical ethics. Family members' participation in the decision making process is insufficient in Spanish PICUs.