[Training in the care of the critical and multiple-injured patient: role of clinical simulation]. / Formación en la asistencia al paciente crítico y politraumatizado: papel de la simulación clínica.

Clinical simulation is suggested as a new educational instrument to learn and train in different medical skills. It is conceived as a new method that integrates scientific knowledge and human factors. Experience with these systems has been limited up to now, but it is now being widely accepted since it seems to accelerate acquisition of skills and knowledge in a safe setting, that is, without risk for the patient. However, its effect on clinical performance has not been validated yet. They are two types of simulators for intensive cares: screen based and human patient simulator (HPS). These systems make it possible to simulate different situations that require the application of action protocols or the management of new drugs in the clinical practice, promoting the rational use of resources in urgent care of the critical and multiple-injured patients. The limiting factors that prevent the expansion of the simulation for clinical training are its high cost, human resources needed, and the difficulties to assess the effectiveness of the training in real situations.

[Mitral insufficiency caused by isolated rupture of the papillary muscle secondary to blunt thoracic trauma]. / Insuficiencia mitral por rotura aislada de músculo papilar secundaria a traumatismo torácico cerrado.

We report a patient suffering from mitral insufficiency after isolated rupture a papillary muscle as a result of a car accident with blunt chest trauma. The diagnosis is often difficult due to related multiple lesions which vary the clinical picture. Physical exploration, electrocardiogram, enzymatic and nuclear scan lack adequate sensitivity and specificity. Echocardiography appears to be the most reliable noninvasive diagnostic method now available.

[A right-to-left shunt through a patent foramen ovale without pulmonary hypertension]. / Cortocircuito derecha-izquierda a través de foramen oval permeable sin hipertensión arterial pulmonar.

We report the case of a man 67-years-old with right-to-left shunt through a patent foramen ovale in absence of pulmonary hypertension. The contrast and transesophageal echocardiography showed significant right-to-left shunt and provided insight about the mechanisms that cause it. The aortic root was enlarged compressing the right atrium. Surgical repair was performed, the foramen ovale was closed and right atrial enlargement with a patch was carried out. Disappearance of the shunt was confirmed by means of transesophageal echocardiography in surgical-room.

[2-dimensional and Doppler echocardiography during atrioseptostomy using the Rashkind method. Alternative umbilical approach in the newborn infant]. / Ecocardiografía 2-D y Doppler durante la atrioseptostomía con técnica de Rashkind. Vía umbilical alternativa en el recién nacido.

Balloon atrial septostomy was performed in 16 patients using 2-D echocardiography (20 D Echo). Patients, 8 hours to 27 days old (5.6 +/- 8.5 days) had cyanotic congenital heart disease: (13 transposition of the great arteries (TGA), 2 pulmonary atresia (AP) and one mitral atresia (AM). In seven patients procedure was performed by way of saphenous-femoral vein. In the nine remaining it was done through umbilical vein, being successful in seven patients (it was necessary to use the saphenous-femoral vein in two). Seven in whom it was possible to use umbilical vein were less than 24 hours old. No complications arose as a consequence of technique, although in one, dissection performed by saphenous vein damaged femoral artery. AS was considered effective in all cases. There was no difference between results obtained by umbilical or saphenous-femoral veins. Umbilical approach proved to be simplest, fastest, and more reliable than saphenous-femoral access in the AS of those patients under 24 hours of age. Special importance is given to the value of 2-D Echo in performing AS and the immediate evaluation of the results and functional evaluation by pulsed Doppler echocardiography.