Pediatric Intentional Self-poisoning Evaluated in the Emergency Department: An International Study.

BACKGROUND: Suicide is a growing public health problem during late childhood and adolescence. The leading method of suicide attempts in this age group is intentional self-poisoning. A first self-poisoning episode is a strong predictor of subsequent suicide and premature death. The objective of this study was to analyze the presentation and management of children younger than 18 years with intentional self-poisonings admitted to an emergency department (ED) in a global research network of pediatric EDs. METHODS: We performed a secondary analysis of a large, international, multicenter, cross-sectional prospective registry of childhood poisoning presentations to 105 EDs in the Pediatric Emergency Research Networks (PERN) network. Data collection started at each ED between January and September 2013 and continued for 1 year. RESULTS: During the study period, we included 1688 poisoning exposures. Of these, 233 (13.8%) were intentional self-poisonings, with significant variation between regions. Female/male ratio was 4.7/1 and most occurred at home. The most common toxicants were therapeutic drugs, mainly psychotropics and analgesics. Ninety patients (38.6%) gave a history of a previous episode of intentional self-poisoning. Sixty-three children (27.0%) were not assessed by a psychiatric service nor transferred to a psychiatric inpatient facility. No patient died. There was significant variation in the involved toxicants and interventions among EDs in different global regions. CONCLUSIONS: Most intentional self-poisoning presentations to pediatric EDs globally are related to intentional ingestions of therapeutic drugs at home by females. Best practices have to be translated into care to guarantee the best outcomes of these patients.

Acute severe paediatric asthma: study protocol for the development of a core outcome set, a Pediatric Emergency Reserarch Networks (PERN) study.

BACKGROUND: Acute severe childhood asthma is an infrequent, but potentially life-threatening emergency condition. There is a wide range of different approaches to this condition, with very little supporting evidence, leading to significant variation in practice. To improve knowledge in this area, there must first be consensus on how to conduct clinical trials, so that valid comparisons can be made between future studies. We have formed an international working group comprising paediatricians and emergency physicians from North America, Europe, Asia, the Middle East, Africa, South America, Central America, Australasia and the United Kingdom. METHODS/DESIGN: A 5-stage approach will be used: (1) a comprehensive list of outcomes relevant to stakeholders will be compiled through systematic reviews and qualitative interviews with patients, families, and clinicians; (2) Delphi methodology will be applied to reduce the comprehensive list to a core outcome set; (3) we will review current clinical practice guidelines, existing clinical trials, and literature on bedside assessment of asthma severity. We will then identify practice differences in tne clinical assessment of asthma severity, and determine whether further prospective work is needed to achieve agreement on inclusion criteria for clinical trials in acute paediatric asthma in the emergency department (ED) setting; (4) a retrospective chart review in Australia and New Zealand will identify the incidence of serious clinical complications such as intubation, ICU admission, and death in children hospitalized with acute severe asthma. Understanding the incidence of such outcomes will allow us to understand how common (and therefore how feasible) particular outcomes are in asthma in the ED setting; and finally (5) a meeting of the Pediatric Emergency Research Networks (PERN) asthma working group will be held, with invitation of other clinicians interested in acute asthma research, and patients/families. The group will be asked to achieve consensus on a core set of outcomes and to make recommendations for the conduct of clinical trials in acute severe asthma. If this is not possible, the group will agree on a series of prioritized steps to achieve this aim. DISCUSSION: The development of an international consensus on core outcomes is an important first step towards the development of consensus guidelines and standardised protocols for randomized controlled trials (RCTs) in this population. This will enable us to better interpret and compare future studies, reduce risks of study heterogeneity and outcome reporting bias, and improve the evidence base for the management of this important condition.

Intoxicación aguda no intencional grave con alcohol isopropílico en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell. A propósito de tres casos clínicos / Acute unintentional poisoning with isopropyl alcohol in the Pereira Rossell Pediatric Emergency Ward. Three clinical cases / Intoxicação aguda não intencional com álcool isopropílico na Emergência Pediátrica do Centro Hospitalar Pereira Rossell. Três relatos de caso

Resumen: Las intoxicaciones agudas en los servicios de emergencia pediátrica ocupan un lugar importante dentro de la patología pediátrica de urgencia por su potencial riesgo vital. El Centro de Información y Asesoramiento Toxicológico (CIAT) recibe anualmente un promedio de 10.000 consultas, el 45% corresponde a la edad pediátrica. La intoxicación aguda por isopropanol es poco frecuente, pero potencialmente grave. El CIAT ha registrado 34 casos en los últimos cinco años. El alcohol isopropílico se encuentra en muchos productos de limpieza y desinfectantes. La intoxicación aguda se caracteriza inicialmente por síntomas digestivos. En la evolución pueden agregarse manifestaciones neurológicas: depresión de conciencia, hipotonía e hiporreflexia, asociada a hipoglicemia, gap osmolar elevado, cetonemia y cetonuria. En casos graves puede ocasionar hipotermia, hipotensión y arritmias. La acidosis metabólica es poco frecuente, a diferencia de otros alcoholes. En este caso, la toxicidad aguda es dependiente en gran medida de la formación de metabolitos. En este trabajo son isopropanol y acetona los responsables de las manifestaciones clínicas y alteraciones en los estudios de laboratorio. Se analizaron tres casos clínicos en niños de 96, 18 y 15 meses. Los tres casos evolucionaron de forma favorable en 72-96 horas, y, como se refiere en la literatura, el pronóstico en general es bueno y sin secuelas. El abordaje de estos pacientes en la urgencia se basa en la aplicación del triángulo de evaluación pediátrica y la secuencia A, B, C, D, E con el propósito de identificar en forma precoz la necesidad de realizar correcciones metabólicas o soporte de funciones.

Summary: Acute poisoning in pediatric emergency services is an important part of the emergency pediatric pathology due to its potential risk. CIAT receives an average of 10,000 consultations annually, 45% of which are from children. Acute isopropanol poisoning is rare but potentially serious. CIAT has recorded 34 cases in the last 5 years. Isopropyl alcohol is found in many cleaning products and disinfectants. Acute poisoning is initially characterized by digestive symptoms. Some neurological manifestations may arise during the acute poisoning evolution, such as, depression of consciousness, hypotonia and hyporeflexia, associated with hypoglycemia, elevated osmolar gap, ketonemia and ketoneuria. In severe cases, it can cause hypothermia, hypotension and arrhythmia. Metabolic acidosis is rare, unlike what happens with other alcohols. In this case, acute toxicity largely depends on the formation of metabolites; in this case, isopropanol and acetone are responsible for clinical manifestations and alterations in laboratory studies. We hereby present three clinical cases of children aged 96, 18 and 15 months. The three cases evolved favorably in 72-96 hours and, as described in the literature, the prognosis in general is good and without sequelae. The approach to these patients in the emergency ward was the pediatric evaluation triangle and the A, B, C, D, E sequence in order to identify early the need to perform metabolic corrections and / or support functions.

Resumo: As intoxicações agudas nos serviços de emergência pediátrica ocupam um lugar importante na patologia pediátrica de emergência devido ao seu risco potencial para a vida. O CIAT recebe, em média, 10.000 consultas anualmente, 45% de pacientes pediátricos. A intoxicação aguda por isopropanol é rara, mas potencialmente grave. O CIAT registrou 34 casos nos últimos 5 anos. O álcool isopropílico encontra-se em vários produtos de limpeza e desinfetantes. O envenenamento agudo é inicialmente caracterizado por sintomas digestivos. Na evolução do envenamento, podem aparecer manifestações neurológicas: depressão da consciência, hipotonia e hiporreflexia, associadas à hipoglicemia, gap osmolar elevado, cetonemia e cetoneúria. Em casos graves, pode causar hipotermia, hipotensão e arritmias. A acidose metabólica é rara, diferentemente do que acontece com outros álcoois. Nesse caso, a toxicidade aguda depende em grande parte da formação de metabólitos; neste caso, isopropanol e acetona são responsáveis pelas manifestações clínicas e alterações em estudos laboratoriais. Analisaram-se três casos clínicos em crianças de 96, 18 e 15 meses. Os três casos evoluíram favoravelmente em 72-96 horas e, como relatamos na literatura, o prognóstico em geral é bom e sem sequelas. A abordagem desses pacientes na emergência foi a aplicação do triângulo de avaliação pediátrica na sequência A, B, C, D, E, a fim de identificar precocemente a necessidade de realizar correções metabólicas e / ou suporte de funções.

International Epidemiological Differences in Acute Poisonings in Pediatric Emergency Departments.

BACKGROUND AND OBJECTIVE: Identifying international differences in the epidemiology of acute poisonings in children may help in improving prevention. We sought to evaluate the international epidemiological differences in acute poisonings in children presenting to emergency departments (EDs) from 8 different global regions. METHODS: This was an international multicenter cross-sectional prospective study including children younger than 18 years with acute poisonings presenting to 105 EDs in 20 countries was conducted. Data collection started at each ED between January and September 2013, and continued for 1 year. RESULTS: During the study period, we registered 363,245 pediatric ED presentations, of which 1727 were for poisoning (0.47%; 95% confidence interval, 0.45%-0.50%), with a significant variation in incidence between the regions. Full data were obtained for 1688 presentations. Most poisonings (1361 [80.6%]) occurred at home with either ingestion (1504 [89.0%]) or inhalation of the toxin (126 [7.6%]). Nonintentional exposures accounted for 1157 poisonings (68.5%; mainly in South America and Eastern Mediterranean region), with therapeutic drugs (494 [42.7%]), household products (310 [26.8%]), and pesticides (59 [5.1%]) being the most common toxins. Suicide attempts accounted for 233 exposures (13.8%; mainly in the Western Pacific region and North America), with therapeutic drugs (214 [91.8%], mainly psychotropics and acetaminophen) being the most common toxins. Significant differences between regions were found in both types of poisonings. Recreational poisonings were more common in Europe and Western Pacific region. No patient died. CONCLUSIONS: There are substantial epidemiological differences in acute poisonings among children in different countries and regions of the globe. International best practices need to be identified for prevention of acute poisonings in childhood.

Urticaria y anafilaxia en un Departamento de Emergencia Pediátrica de referencia en Uruguay: estudio clínico y epidemiológico / Urticaria and anaphylaxia at a Pediatric Emergency Department in a uruguayan reference hospital: clinical and epidemiological trial / Urticária e anafilaxia em emergência pediátrica de referência no Uruguai: estudo clínico e epidemiológico

Resumen: Introducción: las lesiones de piel son motivo frecuente de consulta en la urgencia. La urticaria debe considerarse como un signo clínico y no una enfermedad en sí misma, siendo importante reconocer su forma de presentación, severidad y posibles etiologías para definir una conducta apropiada y oportuna. Objetivo: describir la prevalencia, características clínicas, etiológicas y evolutivas de la consulta por urticaria aisladas o acompañadas de angioedema y/o anafilaxia en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell entre el 1º de julio de 2015 y el 31 de junio de 2016. Materiales y método: estudio retrospectivo mediante revisión de historias. Se incluyeron todos los niños con diagnóstico de urticaria. Variables: edad, sexo, características clínicas, etiologías, estudios, tratamientos, evolución. Resultados: la prevalencia de consulta por urticaria fue 0,8% (405/51.829), varones 54,2%; mediana de edad 4,3 años (22 días-14 años). Manifestaciones cutáneas sin otros síntomas 69,6%; sin angioedema 83,4%, en apirexia 73,4%, con anafilaxia en dos casos. Etiología: infecciosa 29,5%; infecciones respiratorias 78%. Se solicitó al menos un estudio complementario en 16,8% de las consultas. Tratamientos: antihistamínicos 100%, corticoides 45,2%, adrenalina 0,8% (dos casos de anafilaxia). Alta a domicilio 96,8%, hospitalización 3,2%, no fallecimientos. Conclusión: las urticarias representaron 0,8% de las consultas registradas. Los más afectados, niños menores de 3 años con urticaria, en su mayoría sin angioedema, la etiología infecciosa fue la más común. Se registró un bajo porcentaje de hospitalización. En niños con fallo hemodinámico y lesiones de piel, el shock anafiláctico debe ser contemplado. Las medidas de soporte y la administración precoz de adrenalina mejoran el pronóstico vital.

Summary: Introduction: skin lesions are a common cause of emergency consultation. Urticaria should be considered a clinical symptom and not a disease in itself, therefore it is important to recognize its presentation, severity and possible etiologies in order to define appropriate and timely treatment. Objective: describe the prevalence, clinical, etiological and evolutionary characteristics of urticaria alone or accompanied by angioedema and / or anaphylaxis at the Emergency Department of the Pereira Rossell Pediatric Hospital between 7/1/2015- 6/31/2016. Materials and methods: retrospective study carried out through the review of medical records. All children diagnosed with urticaria were included. Variables: age, gender, clinical characteristics, etiologies, tests, treatments, evolution. Results: the prevalence of urticarial consultation was 0.8% (405 / 51,829), males 54.2%; median age 4.3 years (22 days - 14 years). Skin symptoms only 69.6%; without angioedema 83.4%, apyrectic 73.4%, anaphylactic: two cases. Etiology: infectious 29.5%; 78% respiratory infections. At least 1 complementary test was prescribed in 16.8% of the cases. Treatments: 100% antihistamines, 45.2% corticosteroids, 0.8% adrenaline (2 cases of anaphylaxis). 96.8% were discharged and 3.2% were hospitalized, no deaths took place. Conclusion: urticaria accounted for 0.8% of the consultations recorded. Children under 3 years of age were the most affected group by urticaria mostly without angioedema. The most common etiology was infectious. A low percentage of patients were hospitalized. Anaphylactic shock should be considered for the case of children with hemodynamic failure and skin lesions. Support measures and early adrenaline administration improve prognosis.

Resumo: Introdução: as lesões cutâneas são um motivo frequente de consulta na emergência. A urticária deve ser considerada como um sintoma clínico e não uma doença em si, porém é importante reconhecer sua forma de apresentação, gravidade e possíveis etiologias para definir o tratamento apropriado e oportuno. Objetivo: descrever a prevalência, características clínicas, etiológicas e evolutivas da consulta devido à urticária isolada ou acompanhada de angioedema e / ou anafilaxia no Pronto de Emergência Pediátrica do Centro Hospitalar Pereira Rossell, no período de 1/7/2015 a 31/06/2016. Materiais e métodos: estudo retrospectivo, através da revisão de prontuários dos pacientes. Todas as crianças diagnosticadas com urticária foram incluídas. Variáveis: idade, sexo, características clínicas, etiologias, estudos, tratamentos, evolução. Resultados: a prevalência de consulta por urticária foi de 0,8% (405 / 51,829), masculino 54,2% do sexo masculino; idade mediana 4,3 anos (22 dias-14 anos). Manifestações cutâneas sem outros sintomas 69,6%; sem angioedema 83,4%, em apirexia 73,4%, dois casos com anafilaxia. Etiologia: infecciosa 29,5%; 78% de infecções respiratórias. Pelo menos 1 estudo complementar foi solicitado em 16,8% das consultas. Tratamentos: 100% de anti-histamínicos, 45,2% de corticosteróides, 0,8% de adrenalina (2 casos de anafilaxia). Home descarga 96,8%, hospitalização 3,2%, sem mortes. Conclusão: as urticárias representaram 0,8% das consultas registradas. A urticária, principalmente sem angioedema, de etiologia infecciosa, foi a mais comum, principalmente entre as crianças com menos de 3 anos de idade. Uma baixa porcentagem de hospitalização foi registrada. Se deve considerar o choque anafilático em crianças com insuficiência hemodinâmica e lesões cutâneas. As medidas de suporte e a administração precoce da adrenalina melhoram o prognóstico vital.

Exposición no intencional a cannabis en niños en el marco de la regulación del mercado en Uruguay. Reporte de casos asistidos en el Departamento de Emergencia del Centro Hospitalario Pereira Rossell entre marzo y junio de 2017 / Children unintentionally exposed to cannabis within the framework of the Uruguayan Cannabis Sale Regulation. Cases assisted at the Emergency Department of the Pereira Rossell Hospital between March and June 2017 / Exposição não intencional à cânabis em crianças no âmbito do regulamento das vendas do cânabis no Uruguai. Relatório de casos atendidos no Serviço de Emergência do Hospital Pereira Rossell entre março e junho de 2017

Resumen: Introducción: la marihuana es la sustancia de abuso más consumida en América y Europa después del alcohol. En Uruguay la prevalencia es cercana a 23%. El principio activo delta 9-tetrahidrocannabinol es responsable de los efectos psicoactivos. La principal fuente en un niño es una parte de la planta, cigarrillo o comestible con cannabis proveniente de un familiar o vecino. La intoxicación puede ser más severa en niños que en adultos. En Uruguay, en 2013, se aprobó la ley 19.172 que regula el mercado de cannabis, generando un nuevo escenario con potencial riesgo para la población pediátrica. Objetivo: comunicar casos clínicos de intoxicación aguda no intencional por cannabis asistidos entre marzo y junio de 2017, analizar circunstancias de exposición, manifestaciones clínicas, severidad y evolución. Observación clínica: cuatro niños (9 meses, 1, 2 y 8 años) fueron asistidos. En todos ellos la vía de ingreso fue oral en ambiente doméstico. Presentaron síntomas neurológicos agudos: depresión de conciencia, convulsiones, distonías, ataxia, irritabilidad. Requirieron medidas de sostén, descontaminación digestiva y exámenes de laboratorio ampliado. El screening en orina fue positivo en cuatro casos. En dos se realizó la técnica confirmatoria. Aplicando el Poisoning Severity Score, todos sufrieron intoxicación moderada. Se asistieron en conjunto con toxicólogo clínico. Conclusiones: los niños que presentan síntomas predominantemente neurológicos de instalación aguda sin una causa evidente, pueden presentar intoxicación aguda por cannabis, sobre todo cuando en el entorno doméstico hay consumo, cultivo o ambos. Debemos mantener una vigilancia activa. Seguramente futuras investigaciones contribuirán a definir la necesidad de establecer estrategias de prevención destinadas a la población infantil con el objetivo de disminuir el potencial efecto no deseado de este nuevo escenario.

Summary: Introduction: marijuana is most highly consumed abuse substance in America and Europe after alcohol. In Uruguay, the prevalence is close to 23%. The active ingredient, delta 9-tetrahydrocannabinol, is responsible for its psychoactive effects. The main source of access for a child involves a relative and/or neighbor. Intoxication may be more severe in children, In 2013,.cannabis-sale regulating Act 19.172 was approved in Uruguay, and it generated a new potentially risky scenario for children. Objective: report clinical cases of severe unintentional intoxication from cannabis between March and June 2017, and analyze circumstances that led to exposure, clinical manifestations, severity and evolution. Clinical observation: 4 children (9 months, 1, 2 and 8 years of age) were assisted. In all cases, they had ingested cannabis in their home environment. They presented severe neurological symptoms: depressed level of consciousness, convulsive seizures, dystonia, ataxia, irritability. They required supportive measures, digestive decontamination and additional laboratory tests. Urine screening was positive in 4 cases. In 2, we performed confirmatory technique. As per the Poisoning Severity Score, all children suffered moderate intoxication. They were assisted jointly by a clinical toxicologist. Conclusions: children showing predominantly acute neurological symptoms with no apparent cause can be the subject of severe cannabis intoxication, especially when cannabis consumption takes place in their household environments. Surveillance is needed and future research will certainly contribute to the creation of prevention strategies with the purpose of reducing the potential unwanted consequences of this new scenario for children.

Resumo: Introdução: a maconha é a substância do abuso mais consumida na América e na Europa depois do álcool. No Uruguai, a prevalência é próxima de 23%. O ingrediente ativo delta 9-tetrahydrocannabinol é responsável pelos efeitos psicoativos. A principal fonte de acesso à marijuana por parte duma criança é ingerir uma parte da planta, cigarro ou comestível com cânabis de um parente e / ou vizinho. A intoxicação pode ser mais grave em crianças do que em adultos. No Uruguai, em 2013, a Lei 19.172 foi aprovada e regulou a venda de cânabis, gerando um novo cenário com risco potencial para as crianças. Objetivo: relatar casos clínicos de intoxicação aguda não intencional por cânabis atendidos entre março e junho de 2017, analisar as circunstâncias de exposição, manifestações clínicas, gravidade e evolução. Observação clínica: 4 crianças (9 meses, 1, 2 e 8 anos de idade) foram atendidas. Todos eles ingeriram cânabis num ambiente doméstico. Apresentaram sintomas neurológicos agudos: depressão da consciência, convulsões, distonia, ataxia, irritabilidade. Eles precisaram de medidas de suporte, descontaminação digestiva e testes de laboratório adicionais. O screening de urina foi positivo em 4 casos. Em 2, a técnica confirmatória foi realizada. Utilizando o Poisoning Severity Score, todos sofreram intoxicação moderada. Eles foram assistidos conjuntamente pelo toxicologista clínico. Conclusões: é possível que crianças que apresentam sintomas neurológicos predominantemente de instalação aguda sem causa evidente, apresentem intoxicação aguda por cânabis, especialmente quando existe consumo no ambiente ou na cultura domésticos. Nós devemos manter uma vigilância ativa. Com certeza, futuras pesquisas contribuirão para definir estratégias de prevenção para crianças, com o objetivo de reduzir o potencial efeito indesejado desse novo cenário.

Infecciones de piel y partes blandas tratadas en forma ambulatoria en un hospital pediátrico en Uruguay luego de diez años de la epidemia de SAMR / Outpatient skin and soft tissue infections treated in a pediatric hospital in Uruguay after 10 years of MRSA epidemic / Infecções cutâneas e de partes moles com tratamento ambulatorial num hospital pediátrico do Uruguai depois de 10 anos da epidemia SAMR

Resumen: En el año 2001, Staphylococcus aureus meticilino resistente (SAMR) adquirido en la comunidad emergió en Uruguay. Los gérmenes identificados en infecciones de piel y partes blandas variaron, alcanzando 60% el SAMR adquirido en la comunidad. Trabajos nacionales recientes muestran un cambio en las infecciones en niños hospitalizados. Objetivo: determinar la prevalencia de SAMR y su sensibilidad a los antibióticos en niños con tratamiento ambulatorio. Metodología: estudio descriptivo, prospectivo. Inclusión: todos los niños que consultaron en un Departamento de Emergencia Pediátrico por lesiones de piel y partes blandas con tratamiento ambulatorio y aislamiento de germen. Se realizó seguimiento telefónico a las 72 horas. Período: 10 de diciembre de 2015 al 31 de marzo de 2016. Resultados: se incluyeron 194 consultas por infecciones de piel y partes blandas en las que se indicaron tratamiento ambulatorio y se identificó agente etiológico. El diagnóstico más frecuente fue impétigo 181/194 (93%). Etiología: SA 152 (SA meticilino sensible [SAMS] 151, SAMR 1), EBHGA 3, EBHGB 3, coinfecciones 32 (16%), otros 4. Las 32 coinfecciones fueron SAMS con otro agente. Tratamiento antibiótico utilizado: tópico más oral 99, tópico 54, oral 21, sin antibiótico 20. Se logró seguimiento telefónico en 166 pacientes (86%). Presentaron buena evolución 165, reconsultaron cinco niños, ninguno fue hospitalizado. Conclusiones: SA solo o asociado sigue siendo el principal agente en infecciones de piel y partes blandas que reciben tratamiento ambulatorio en la población estudiada. SAMR fue el responsable del 47% de las infecciones estafilocóccicas de tratamiento ambulatorias en estudio previo. En esta serie, SAMR representa el 0,6% (p <0,05). El descenso de las infecciones producidas por SAMR coincide con los hallazgos en los pacientes hospitalizados realizado en el mismo hospital. La vigilancia periódica permite reevaluar las recomendaciones de tratamiento empírico inicial y modificarlas si fuera necesario.

Summary: There was an outbreak of community-acquired methicillin-resistant staphylococcus aureus (MRSA) in Uruguay in 2001. The identified germs found in skin and soft tissue infections (S and ST) varied, and reached 60%. Recent studies in Uruguay have shown changes in the types of infections acquired by hospitalized children. Objective: to determine MRSA prevalence and susceptibility to antibiotics in outpatient children . Methodology: a descriptive prospective study. Target: outpatient children consulting at ER for S and ST lesions who received germ isolation. Telephone follow-up after 72 hours. Time period : from December 10th 2015 to March 31st, 2016. Results: S and ST appointments: 797 (7 % of the total). Ambulatory visits: 691. Outpatients with identified etiologic agent: 194. Females: 102, mean and median age: 4 years of age. More frequent diagnosis: impetigo 181/194 (93%) Etiology: SA 152(MSSA 151, MRSA 1), beta hemolytic streptococci: BHGA 3, BHGB 3, coinfections 32 (16%), others 4. 32 of coinfections were MSSA plus another agent. Treatment with antibiotics: 99 received topical plus oral treatment, 54 received topical treatment, 21 received oral treatment, 20 received treatment that did not include antibiotics . Follow-up: 166 patients (86%). Good evolution: 165, repeated appointments: 5, hospitalized: none. Conclusions: Single SA or associated SA continues to be the main agent of S and ST infections that receive outpatient treatment. MRSA was responsible for 47% of ambulatory staphylococcal infections in the previous study. MRSA represents 0.6 (p¼0.05) in this series. Continuous surveillance has enabled us to reassess the initial empirical epidemiological treatment and to change it if necessary.

Resumo: Em 2001, o Staphylococcus aureus resistente à meticilina (MRSA) adquirido na comunidade surgiu no Uruguai. Os germes identificados nas infecções da pele e tecidos moles (P e PB) variaram, chegando a 60% do MRSA adquirido na comunidade. Estudos nacionais recentes mostram uma mudança nas infecções nas crianças hospitalizadas. Objetivo: determinar a prevalência de MRSA e sua sensibilidade aos antibióticos em crianças com tratamento ambulatorial. Metodologia: Estudo descritivo, prospectivo. Amostra: todas as crianças que consultaram a um Serviço de Emergência Pediátrica por lesões de P e PB com tratamento ambulatorial e isolamento de germes. Se realizou seguimento telefónico às 72 horas. Período: do 10 de dezembro de 2015 a 31 de março de 2016. Resultados: foram incluídas 194 consultas por infecções por P e PB, nas quais indicou-se tratamento ambulatorial e identificou-se agente etiológico. O diagnóstico mais frequente foi o impetigo 181/194 (93%). Etiologia: SA 152 (SAMS 151, SAMR 1), EBHGA 3, EBHGB 3, coinfecções 32 (16%), outras 4. As 32 coinfecções foram SAMS com outro agente. Tratamento antibiótico utilizado: oral tópico 99, tópico 54, oral 21, sem antibiótico 20. Se realizou seguimento telefónico para o caso de 166 pacientes (86%). Apresentaram boa evolução 165, reconsultaram 5 crianças, nenhuma foi internada. Conclusões: a infecção por SA isoladamente ou associada permanece como o principal agente nas infecções por P e PB que recebem tratamento ambulatorial na população estudada. O MRSA foi responsável por 47% das infecções estafilocócicas do tratamento ambulatorial num estudo anterior. Nesta série, o MRSA representa 0,6% (p <0,05). A diminuição das infecções produzidas por MRSA coincide com os dados achados em pacientes hospitalizados no mesmo hospital. A vigilância periódica torna possível reavaliar as recomendações empíricas iniciais de tratamento e modificá-las, se for necessário.

Mordeduras por animales en niños. ¿Cuál es la situación actual en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell? / Animal bites in children. What is the current situation in the Pediatric Emergency Department at Pereira Rossell Hospital?

Resumen: Las mordeduras de animales ocupan el 1% de las consultas en urgencias. En la mayoría el animal agresor es el perro, pudiendo generar lesiones de diversa gravedad, complicaciones infecciosas y secuelas. Objetivos: conocer la incidencia de mordeduras de animales en DEP-CHPR, características de la población, lesiones infligidas y conducta inicial. Material y método: estudio descriptivo, retrospectivo de pacientes que consultaron en DEP-CHPR por mordedura de animal, entre el 1/1/2013 y el 31/12/2015. Fuente: historias clínicas informatizadas. Se utilizó Epi-Info versión 3.5.4. Resultados: 872 niños mordidos (0,5% del total de consultas). Varones 544 (62%). Edad media 6 años (1 mes-14 años). Verano y primavera: 505 consultas (58%). En 442 pacientes (50%) animal conocido. Animal agresor: perro 837 (96%). Localización: Cara y cuero cabelludo: 478 (55%); media de edad 4,2 años. En miembros 327 (37,5%), múltiples 73 (8,4%). Severidad: leves 790 (90%), severa 7 (0,8%). Destino: domicilio 802 (92%), cuidados moderados 63 (7,2%), cuidados intensivos 7 (0,9%). No fallecimientos. En 428 (49%) suturas. Antibiótico profiláctico: 770 (88%). Secuelas estéticas: 26 (3%). Vacuna antitetánica vigente: 852 (98%). Notificación al Ministerio de Salud: 148 (17%). Conclusiones: este tipo de lesiones persisten con resultados similares a estudios anteriores. Los niños más pequeños sufren heridas más graves que afectan predominantemente cara y cuero cabelludo. Los pacientes mordidos requieren un abordaje integral: manejo de las lesiones, evaluación de riesgo de zoonosis y prevención de complicaciones. La adherencia al tratamiento antibiótico profiláctico fue elevada. Es necesario difundir protocolos de actuación y tratamiento que incluyan la notificación obligatoria y fortalecer las medidas de prevención primaria.

Summary: Animal bites represent 1% of emergency visits. In most cases attacking animals are dogs, causing lesions of variable entity, infectious complications and sequelae. Objectives: to learn about the incidence of animal bites in the Pediatric Emergency Department at Pereira Rossell Hospital, the characteristics of this population, the kind of lesions and their initial management. Method: descriptive, retrospective study including patients in the Pediatric Emergency Department at Pereira Rossell Hospital who consulted for animal bites between 1/1/13 - 12/31/15. Source: computerized clinical registries. Epi-Info version 3.5.4. was used. Results: 872 bitten children were included in the study (0.5% of total visits). Male 544 (62%). Median age was 6 years old (1 month -14 years), consultations in summer and spring 505 (58%). In 442 patients (50%) the animal was known. Attacker animal: dog 837 (96%). As to the site, face and scalp added up to 478 (55%); median age being 4.2 years old, and bites in the limbs added up to 327 (37.5%), multiple lesions were seen in 73 children (8.4%). Regarding severity: mild 790 (90%) and severe 7 (0.8%). Outcome: 802 children we discharged (92%), 63 were admitted (7.2%), admitted in the intensive care unit 7 (0.9%). No deaths we recorded. In 428 (49%) of cases suture was needed. Prophilactic antibiotic: 770 (88%). Aesthetic sequelae in 26 children (3%). Tetanus vaccine: 852 (98%). Notification to the Ministry of Health: 148 (17%). Conclusions: this kind of lesions persist, similar to previous local studies. Younger children suffer more severe lesions affecting mostly their face and scalp. Bitten patients require a comprehensive approach: injury management, evaluation of zoonosis risk and prevention of complications. Adherence to antibiotic treatment was high. It is necessary to spread management protocols that include compulsory notification to authorities and to strengthen the prevention measures.

Consulta adolescente en servicios de emergencia pediátrica / Adolescent consultations at the peadiatrics emergency service

La Organización Mundial de la Salud define como adolescencia la etapa comprendida entre los 10 y 19 años (temprana: 10 a 14 años; tardía: 15 a 19 años). La prevalencia de enfermedades en la adolescencia es baja; sin embargo, los adolescentes utilizan los servicios de emergencia, lo que requiere un abordaje integral y multidisciplinario. No hay datos publicados sobre los motivos de consultas de adolescentes en Uruguay. Objetivo: conocer la frecuencia y las características de la consulta de adolescentes en los servicios de emergencia del subsector público y privado del sistema nacional integrado de salud. Metodología: estudio multicéntrico, retrospectivo, de adolescentes de entre 10 y 14 años que consultaron en el Hospital Pediátrico-Centro Hospitalario Pereira Rossell de la Administración de los Servicios de Salud del Estado, subsector público, y entre 10 y 19 años en la Asociación Española Primera de Socorros Mutuos, en el Centro de Asistencia Médica del Oeste de Colonia y en Casa deGalicia. Se incluyeron las consultas registradas entre los días 7 y 13 de los meses de enero, abril, julio y octubre del 2013. Se registraron: edad, sexo, motivo de consulta, comorbilidades, consultas con especialistas, exámenes de laboratorio, diagnóstico y destino al egreso. Se realizó análisis estadístico, considerando estadísticamente significativo p <0,05. Resultados: n=1.518, 9% del total de consultas. Edad: media 13 años 1 mes, varones 50,5%; tenía comorbilidades: 26%. Subsector público 35%; subsector privado, instituciones de asistencia médica colectiva (IAMC) 65%. Distribución de consultas por mes: enero 20%, abril 30%, julio 20%, octubre 30%. Los motivos de consulta más frecuentes fueron lesiones e injurias: 33%; síntomas respiratorios: 14%; otros: 13%; síntomas digestivos: 12,5%; lesiones en piel: 7%. Los problemas psicosociales fueron 7,2% en el sector público, en tanto que en el privado fue 3,2%. Consulta con especialista: 38%. Laboratorio: 16%. Imágenes: 30%. Diagnósticos principales al egreso: trauma 33%; patología respiratoria 20%; otros 13%; patología digestiva 10%; patología de piel 6,6%. Destino final: domicilio 90%; hospitalización en el subsector público 13%; en IAMC 8%. El 0,9% se retira antes de la asistencia, 0,1% se institucionaliza. Conclusiones: si bien la consulta de adolescentes es de baja prevalencia, lamisma genera un impacto en los servicios de urgencia por la elevada utilización de recursos. Se observan diferencias entre el sector público y el privado.

The WHO defines an adolescent as any person between ages 10 and 19 (early adolescence being between 10 and 14 years old, late adolescence being between 15 and 19 years). The prevalence of diseases in adolescents is low, although they use the emergency services and thus require a comprehensive and multidisciplinary approach. No data has been published on the reasons for the consultation of adolescents in Uruguay. Objective: the aim of this study was to determine the frequency and characteristics of adolescent consultations at the emergency services in the public and private subsector of the national integrated health system. Method: multicenter, retrospective study of adolescents between ages 10 and 14 years old who consulted at the Pereira Rossell Hospital HP-CHPR (public sector) and between 10 and 19 years old in AE, CAMOC, CG (private sector). The study included consultations from 7th to 13th January, April, July and October 2013, and the following data were recorded: age, sex, chief complaint, comorbidities, specialist consultations, laboratory tests, diagnosis and destination upon discharge. Statistical analysis was performed, being p <0.05 statistically important. Results: n = 1518, representing 9% of all consultations. Age: mean 13 years 1 month, male: 50.5%; comorbidities: 26%. Public sector 35%; private sector: 65%. Distribution of consultations per month: January 20%, April 30%, May 20%, October 30%. The most frequent reasons for consultation were lesions and injuries 33%, respiratory symptoms 14%, other 13%, 12.5% gastrointestinal symptoms, skin lesions 7%. Psycho-social problems represented 7.2% in the public sector and 3.2% in the public sector. Consultation with a specialist 38%; laboratory: 16%; imaging techniques 30%. Main diagnoses upon discharge: 33% trauma, 20% respiratory disease, 13% other, 10% gastrointestinal pathology, 6.6% pathology of skin 6,6%. Final destination: 90% home, 13% hospital in the public sector, 8% hospital in the private sector, 0.9% leave the emergency service before assistance, 0.1% institutionalized. Conclusions: while adolescent consultation has a low prevalence, it has a significant impact on emergency services due to its use of resources. Differences are observed between the public and private sector.

A OMS define adolescência como a etapa compreendida entre os 10 e 19 anos (precoce: 10 e 14 anos; tardia: 15 a 19 anos). Embora a prevalência de doenças na adolescência seja baixa os adolescentes utilizam serviços de emergência, o que requer uma abordagem integral e multidisciplinar. Não existem dados publicados sobre os motivos de consultas dos adolescentes no Uruguai. Objetivo: o objetivo deste estudo é conhecer a frequência e as características da consulta de adolescentes nos serviços de emergência do subsetor público e privado do sistema nacional integrado de saúde. Metodología: estudo multicêntrico, retrospectivo de adolescentes entre 10-14 anos que consultaram no HP-CHPR (Hospital Pediátrico Centro Hospitalario Pereira Rossell da Administración de Salud del Estado (ASSE): subsetor público) e entre 10-19 anos na AE (Asociación Española Primera de Socorros Mutuos), CAMOC (Centro de Asistencia Médica del Oeste de Colonia), CG (Casa de Galicia) (Instituições de Assistência Médica Coletiva: IAMC). Foram incluídas as consultas dos dias 7 a 13 dos meses janeiro, abril, julho e outubro de 2013. Foram registrados: idade, sexo, motivo de consulta, comorbidades, consultas com especialistas, exames de laboratório, diagnóstico e destino na alta. Foi realizada umaanálise estadística considerando estatisticamente significativo p <0.05. Resultados: n=1518, 9% do total de consultas. Idade: média 13 anos e 1 mês, 50,5% eram do sexo masculino e 26% apresentavam comorbidades. 35% foram atendidos no subsetor público e 65% no subsetor privado (IAMC). A distribuição mensal de consultas foi: janeiro 20%, abril 30%, julho 20%, outubro 30%. Os motivos de consulta mais frequentes foram lesões 33%, sintomas respiratórios 14%, outros 13%, sintomas digestivos 12,5%, lesões na pele 7%. Os problemas psicossociais ccorrespondiam a 7,2% no setor público, e a 3,2% no privado. Consulta com especialista 38%. Laboratorio: 16%. Imagens 30%. Diagnósticos principais na alta: trauma 33%, patologia respiratória 20%, outros 13%, patologia digestiva 10%, patologia de pele 6,6%. Destino final: domicilio 90%, hospitalização: 13% no subsetor público e 8%nas IAMC. 0,9% se retira antes da assistência, 0,1% se institucionaliza. Conclusões: embora a consulta de adolescentes tenha baixa prevalência, esta gera um impacto nos serviços de urgência pela elevada utilização de recursos. Foram observadas diferenças entre o setor público e privado.

[A five-year experience with zoonotic Salmonella at a pediatric reference centre]. / Un quinquenio de experiencia (2005-2010) con infecciones por Salmonella spp en un centro nacional de referencia en pediatría.

BACKGROUND: Salmonella can cause asymptomatic infections, diarrhea, bacteremia and focal infections such as meningitis and osteomyelitis. AIM: To describe clinical and microbiological aspects of infections by Salmonella spp. in children in a pediatric referral hospital: Centro Hospitalario Pereira Rossell, in Montevideo, Uruguay. MATERIALS AND METHODS: Descriptive and retrospective study of 46 patients, from which Salmonella spp was isolated between January 1, 2005 and December 31, 2010. RESULTS: Salmonella spp was isolated in 46 children younger than 15 years old. 18 were below 2 years old and 5 children below three months. 24% of the children had risk factors, such as HIV infection, oncological diseases and malnutrition; low birth weight and pneumonia were associated conditions. No deaths were reported. The serotypes more frequently found were: Typhimurium and Enteritidis. Most of the strains were susceptible to ampicillin and third generation of cephalosporins. DISCUSSION: Diarrhea with blood was the predominant clinical presentation, and there were no outbreaks. Typhimurium and Enteritidis were the most common serotypes. Based on the profiles of susceptibility antimicrobial, we could maintain the same recommendations until the moment suggested. CONCLUSIONS: we must consider the Salmonella infection in febrile children under risk of an invasive bacterial disease, with or without focal infection.

Pirotecnia: lesiones graves de mano asociadas a explosión de un tipo de dispositivo (megapetardo/superbomba) / Pyrotechnics: severe hand lesions associated to the explosion of a certain device (megafirecrackers/superbombs)

Resumen Introducción: el uso de fuegos artificiales y dispositivos de pirotecnia forma parte de celebraciones y espectáculos públicos en todo el mundo. En Uruguay, su uso se encuentra concentrado en los meses estivales en eventos públicos y privados. Hay normativas para su uso, la importación y venta está regulada. En el verano de 2014-2015 hubo cuatro niños con lesiones graves de mano producidas por explosivos. Todas en circunstancias similares, compartieron el mismo mecanismo lesional y vinculados a un único dispositivo. En el año 2016 hubo más niños con iguales injurias. Objetivo: comunicar una serie de niños con injurias provocadas por un tipo de explosivo de pirotecnia con un patrón diferente al conocido previamente. Resultados: n=6. Todos varones, cinco adolescentes. Los seis presentaron lesiones severas en manos con amputación de uno o varios dedos, determinando secuelas estéticas y funcionales. Discusión: se identifica los dispositivos con alto contenido en pólvora y el mal uso de los mismos como factores asociados a las lesiones graves de mano. Se realizó una campaña desde la Sociedad Uruguaya de Pediatría, el Departamento de Emergencia Pediátrica, el Ministerio de Salud y otras autoridades para abordar este problema. Se prohíbe la venta de ese dispositivo. Conclusiones: la utilización de dispositivos de pirotecnia con alto contenido de pólvora como el megapetardo o superbomba puede determinar lesiones graves de mano, mutilantes y secuelas permanentes. No se recomienda la manipulación de fuegos artificiales por parte de los niños. El cumplimiento de las normativas vigentes y el correcto uso de los mismos podrían contribuir a disminuir estas injurias.

Summary Introduction: the use of fireworks and pyrotechnic devices are ways of public entertainment and celebration around the world. In Uruguay, they are more frequently used during summer-time in public and private events. Usage, import and sales are regulated by law. In summer 2014-2015 four children presented severe hand injuries caused by blasts, all of which occurred under similar conditions, shared the same injury mechanism and were linked to a specific device. In 2016 there were more children with similar lesions. Objective: to report a series of children with hand lesions caused by a certain type of pyrotechnic device with a pattern that was different from the one previously known. Results: n=6. All of them males 5 adolescents. The 6 children studied presented severe lesions in hands with amputation of 1 or several fingers, which resulted in aesthetic and functional sequelae. Discussion: devices with a high dose of gunpowder and their incorrect use are identified as factors associated to severe lesions. The Uruguayan Society of Pediatrics, the Pediatrics Emergency Department and the Ministry of Health, among other authorities, conducted a campaign to address this issue. The sale of this device is prohibited. Conclusions: the use of pyrotechnic devices with a high dose of gunpowder such as mega firecrackers or superbombs can result in severe hand lesions, mutilation and permanent sequelae. The handling of fireworks by children is not recommended. Fulfillment of updated regulations and the correct use of fireworks might contribute to diminishing these injuries.

International Variability in Gastrointestinal Decontamination With Acute Poisonings.

BACKGROUND AND OBJECTIVES: Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings to emergency departments. METHODS: This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists' recommendations. Multivariate logistic regression was performed to identify independent risk factors for performing GID procedures. RESULTS: We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1%-22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5%-51.2%), the GID procedure was considered appropriate, with significant differences between regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region where the intoxication occurred (P < .001). CONCLUSIONS: Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented.

Un quinquenio de experiencia (2005-2010) con infecciones por Salmonella spp en un centro nacional de referencia en pediatría / A five-year experience with zoonotic Salmonella at a pediatric reference centre

Resumen Introducción: Salmonella sp puede causar infecciones asintomáticas, gastroenteritis, bacteriemia e infecciones focales como meningitis y osteomielitis. Objetivo: Describir aspectos microbiológicos y clínicos de las infecciones por Salmonella spp en niños en un hospital de referencia pediátrico Centro Hospitalario Pereira Rossell. Montevideo Uruguay. Material y Métodos: Estudio descriptivo y retrospectivo de pacientes en quienes se aislara Salmonella spp en el período 1 de enero de 2005 al 31 de diciembre de 2010. Resultados: Se aisló Salmonella spp en 46 niños menores de 15 años. Dieciocho eran menores de 2 años y 5 niños menores de tres meses. 24% de los pacientes presentaba factores de riesgo (infección por VIH; enfermedad hemato-oncológica, desnutrición) y co-morbilidades (bajo peso al nacer y neumonía). No hubo fallecidos. Los serotipos más frecuentes fueron: Typhimurium y Enteritidis. La mayoría de las cepas eran sensibles a ampicilina y cefalosporinas de tercera generación. Discusión: La presentación clínica predominante fue diarrea con sangre, no se presentaron brotes. Basados en los perfiles de susceptibilidad antimicrobiana, se pueden mantener las recomendaciones hasta el momento sugeridas. Conclusiones: Se debe tener en cuenta la infección por Salmonella sp en niños febriles con riesgo de enfermedad bacteriana invasora, con o sin focalidad.

Background: Salmonella can cause asymptomatic infections, diarrhea, bacteremia and focal infections such as meningitis and osteomyelitis. Aim: To describe clinical and microbiological aspects of infections by Salmonella spp. in children in a pediatric referral hospital: Centro Hospitalario Pereira Rossell, in Montevideo, Uruguay. Materials and Methods: Descriptive and retrospective study of 46 patients, from which Salmonella spp was isolated between January 1, 2005 and December 31, 2010. Results: Salmonella spp was isolated in 46 children younger than 15 years old. 18 were below 2 years old and 5 children below three months. 24% of the children had risk factors, such as HIV infection, oncological diseases and malnutrition; low birth weight and pneumonia were associated conditions. No deaths were reported. The serotypes more frequently found were: Typhimurium and Enteritidis. Most of the strains were susceptible to ampicillin and third generation of cephalosporins. Discussion: Diarrhea with blood was the predominant clinical presentation, and there were no outbreaks. Typhimurium and Enteritidis were the most common serotypes. Based on the profiles of susceptibility antimicrobial, we could maintain the same recommendations until the moment suggested. Conclusions: we must consider the Salmonella infection in febrile children under risk of an invasive bacterial disease, with or without focal infection.

Cánula nasal de alto flujo en niños con crisis asmática en un servicio de urgencias pediátrico / High-flow nasal cannula therapy in children with severe asthma exacerbations in a pediatric emergency department

Resumen: Introducción: la oxigenoterapia por catéter nasal de alto flujo (CNAF) es un recurso terapéutico probado en la insuficiencia respiratoria aguda en lactantes; hay pocos trabajos en niños mayores en la urgencia pediátrica. Se aplica en el Departamento de Emergencia Pediátrica (DEP) del Centro Hospitalario Pereira Rossell (CHPR) desde 2013 en lactantes con broncoobstrucción. Publicaciones recientes avalan su aplicación en niños de todas las edades. Objetivos: comunicar la experiencia con el uso de CNAF en pacientes mayores de 2 años con crisis asmática moderada-severa en el DEP-CHPR. Material y métodos: estudio descriptivo, retrospectivo, de niños mayores de 2 años con crisis asmática asistidos con CNAF en el DEP-CHPR entre 01/06/13 y el 31/08/2016. La severidad de la crisis asmática se evaluó siguiendo el Pediatric Asthma Score (severa > 11, moderada 8 a 11). Se utilizó equipo Fisher Paykel, con flujímetro de hasta 70 L/min. Resultados: 78 pacientes (41 niñas). Crisis asmática moderada 34; severa 44. PAS: media 11 (9-14). Flujo máximo: media 30 L/m (12-60). Duración OAF en DEP: media 15 h (1-46). CNAF como único soporte respiratorio: 42; ventilación no invasiva 33. AVM: tres pacientes. En un paciente: se detectó neumotórax hipertensivo en la radiografía realizada después del inicio de la CNAF. No hubo fallecimientos. Conclusiones: la CNAF resultó un recurso terapéutico sencillo y accesible para el tratamiento inicial de niños mayores de 2 años con fallo respiratorio. Se utilizaron flujos de 2 L/kg/min, con buena tolerancia. Constituyó el único soporte respiratorio en la mitad de este grupo. Su indicación temprana en el tratamiento escalonado de la crisis asmática en la emergencia ha aumentado; deberá considerarse en los protocolos de atención de la crisis asmática.

Summary: Introduction: high flow nasal cannula is used for the treatment of acute respiratory failure in infants, although there are few publications referred to older children in the Emergency Department. HFNC has been used at the Pediatric Emergency Department (PED) of Pereira Rossell Hospital since 2013, in infants with bronchial obstruction. Recent research has found it may be recommended for children of all ages. Objectives: to describe the experience in the use of HFNC in patients older than 2 years old, when they presented moderate and severe asthma exacerbation episodes at the in Pediatric Emergency Department of Pereira Rossell Hospital. Method: descriptive, retrospective study including children older than 2 years old with asthma exacerbations treated with HFNC, at the in Pediatric Emergency Department of Pereira Rossell Hospital between 06/01/13 - 08/31/16. The severity of acute asthma was evaluated with the Pediatric Asthma Score (severe being > 11, and moderate from 8 to 11). Fisher Paykel CNAF equipment was used up to 70 L/min. Results: 78 patients (41 female): Moderate exacerbation 34; severe 44. PAS: median 11 (9-14). Maximum flow: median 30L/m (12 - 60). HFNC in PED: median 15 h (1-46). HFNC as the only respiratory support: 42; non- invasive ventilation: 33. MVA: 3 patients. 1 patient: hypertensive pneumothorax in x-ray performed after the initiation of HNFC. No deaths recorded. Conclusions: HNFC was a simple and accessible therapy for the initial treatment of children older than 2 years old with acute respiratory failure. Oxygen flows of 2 L/k/min were used and no complications arose. It was the only respiratory support in half of these children. Its early indication in progressive treatment of acute asthma has increased. HNFC should now be included in protocols for management of asthma exacerbations.

Impacto de la implementación de oxigenoterapia de alto flujo en el manejo de la insuficiencia respiratoria por infecciones respiratorias agudas bajas en un departamento de emergencia pediátrica / Impact of high flow nasal cannula oxygen in the management of acute respiratory failure in a Pediatric Emergency Department

Introducción: la oxigenoterapia de alto flujo (OAF) administrada por cánulas nasales, se ha instaurado como una técnica sencilla, fácil de administrar, de bajo costo, sin complicaciones graves, efectiva para el tratamiento de la insuficiencia respiratoria (IR) en infecciones respiratorias agudas bajas (IRAB). Su aplicación temprana podría mejorar la evolución de estos niños. Objetivos: comunicar la primera experiencia con OAF en niños con IRAB en un Departamento de Emergencia Pediátrica (DEP). Compararla con una cohorte histórica de niños que no la recibió. Métodos: estudio descriptivo, prospectivo (1 de junio de 2013-20 de setiembre de 2013). Todos los niños tratados con OAF en DEP del Centro Hospitalario Pereira Rossell. Criterios de inclusión: <2 años con IRAB viral con IR y escore de Tal >8 o ³7 mantenido, apneas reiteradas, saturación de oxígeno <90% con O2 por máscara de flujo libre. Criterios de exclusión: pCO2 >70 mmHg, pH <7,2, depresión de conciencia, falla hemodinámica. Resultados: OAF 36 niños; mediana 4 meses; bronquiolitis 83%; VRS+ 58%. Destino pacientes en OAF: cuidados moderados 78%, UCI 22%, AVM 22%. No complicaciones ni fallecimientos. Cohorte histórica: 91 niños con IRAB no tratados con OAF. Cohorte histórica: UCI: 40 (44%) versus OAF (p=0,0005). AVM: cohorte histórica 30 (33%) versus OAF (p=0,026). Menores 6 meses: con OAF AVM 5 (19%), cohorte histórica: 25(45%) (p=0,026). Conclusiones: en un porcentaje elevado de pacientes fue posible evitar el ingreso a UCI. La necesidad de AVM en menores de 6 meses con OAF fue significativamente menor. La incorporación temprana de OAF en las IRAB graves modificó la forma de tratamiento de estos pacientes en la emergencia.

Introduction: high flow nasal cannula oxygen (HFNC) has become a simple, easy to implement, non-expensive technique, without serious complications, to treat respiratory failure in lower respiratory tract infections (LRTI). Its early implementation could improve outcome in these children. Objectives: to communicate the first experience with HFNC in children with LRTI in a Pediatric Emergency Department. To compare it with a historical cohort of children who did not receive HFNC. Methods: descriptive, prospective study (01/06/13-20/09/2013). Every child treated with HFNC in the Emergency Department -Pereira Rossell Hospital. Inclusion criteria: <2 years old with viral LRTI, respiratory failure and Tal score >8 or persistent ³7, persistent apnea, oxygen saturation <90% with O2 mask. Exclusion criteria: pCO2>70 mmHg, pH<7.2, depression of consciousness, hemodynamic failure. Results: HFNC 36 children; median age 4 months; bronchiolitis 83%; VRS+ 58%. Destination HFNC patients: admission 78%, PICU 22%, MV 22%. No complications, no deaths.. Historic cohort: 91 children with LRTI not treated with HFNC; PICU: 40(44%) vs HFNC (p=0.0005). MV: historic cohort 30(33%) vs HFNC (p=0.026). Younger than 6 months: HFNCO MV 5(19%), historic cohort: 25(45%) (p=0.026). Conclusions: admission to PICU was prevented in a high number of patients. Need for MV in patients younger than 6 months with HFNC was significantly lower. The early application of HFNC in severe LRTI modified the treatment of these patients in the emergency department.

Aspiración de cuerpos extraños en la emergencia del hospital pediátrico: Manejo de diez casos y actualización / Foreign body aspiration in the Emergency Unit at the pediatrics hospital: Handling of ten cases and update

Introducción: la aspiración de un cuerpo extraño es causa importante y prevenible de morbimortalidad en la infancia, principalmente en menores de 3 años. En ausencia de un adulto que presencie el episodio de sofocación o atragantamiento, el diagnóstico puede dificultarse, retrasándolo. Objetivo: conocer las características clínicas e imagenológicas de los pacientes que al arribo al DEP se planteó el diagnóstico de obstrucción de vía aérea (OVA) por cuerpo extraño (CE) y actualización. Metodología: estudio descriptivo, observacional y retrospectivo de las historias clínicas de 10 niños ingresados a la URE del DEP con diagnóstico de OVA por CE entre el 1 de enero de 2010 y el 31 de diciembre de 2013, analizando edad, sexo, hora del accidente, procedencia, lugar, medio social, presencia de adulto, examen físico, imagenología, naturaleza del CE, localización anatómica, maniobras practicadas, primera asistencia, tiempo hasta su expulsión/extracción, complicaciones y destino de los pacientes. Resultados: siete de los diez niños fueron varones; edades entre 6 meses y 13 años; nueve de Montevideo y área metropolitana. En los casos presenciados por adultos -nueve- se consultó dentro de las 24 horas. En siete se trató de material orgánico (carne, fruta, semillas) durante la alimentación (almuerzo, cena), y en tres ocasiones no orgánico, uno radioopaco. Nueve niños estaban en su hogar y uno en la escuela. La primera asistencia en seis casos consistió en maniobras realizadas por familiares (barrido de boca con el dedo) o personal de salud (maniobra de Heimlich) siendo inefectivas. En ocho casos los hallazgos del examen físico coincidieron con el diagnóstico planteado. La radiología mostró el CE o signos indirectos. La eliminación espontánea ocurrió en dos ocasiones; en dos se extrajo en el DEP, y en seis mediante broncoscopio rígido bajo anestesia general, de bronquio fuente derecho en cuatro y de bronquio fuente izquierdo en dos. No se registraron complicaciones y todos los pacientes fueron dados de alta. Comentarios: es una patología de baja incidencia. Distribución bimodal, con picos a los ocho meses y a los ocho años, en domicilio y a predominio de material orgánico. Alta participación de adultos sin hábitos de puericultura y de medio social deficitario puede incidir en su ocurrencia. El síndrome asfíctico con confirmación posterior de aspiración estuvo presente en nueve casos. La exploración física y la imagenología fueron de utilidad. Las maniobras que buscan desobstruir la vía aérea fueron inefectivas. La extracción en block quirúrgico con broncoscopio rígido continúa siendo de elección. No se registró morbimortalidad inmediata al episodio. Se debe insistir en la divulgación de medidas preventivas en padres y cuidadores así como contar con regionalización y transporte pediátricos adecuados.

Introduction: foreign-body aspiration is a preventable cause of morbidity and mortality in childhood, especially in children under 3 years old. Diagnosis may be difficult and it may be delayed when no adult witnesses the choking episode. Objective: to learn about clinical and imaging characteristics of patients who, upon arrival at DEP are primarily diagnosed with airway obstruction by foreign body and to provide an update on this condition. Methodology: descriptive, observational and retrospective study of clinical histories of 10 children admitted to the DEP of the Emergency Unit diagnosed with airway obstruction by foreign body between 01/01/2010 and 12/31/2013. Age, sex, time of the accident, origin, location, social environment, adult presence, physical examination, imaging, nature of the foreign body, anatomical location, manoeuvres practiced, first aid, time until their expulsion / removal, complications and patient destination were analysed. Results: seven out of ten children were male; ages 6 months and 13 years; nine in Montevideo and the metropolitan area. When the episodes were witnessed by adults, consultations took place within 24 hours. In seven cases organic material was the reason of choking (meat, fruit, seeds) during meals (lunch, dinner), and in three cases obstruction resulted from non-organic, radiopaque material. Nine children were at home and one in the school. The first assistance in six cases consisted in manoeuvres by relatives (sweeping the mouth with a finger) or health staff (Heimlich) being this ineffective. In eight cases the physical examination findings confirmed diagnosis. Radiology showed the foreign body or indirect signs. Spontaneous elimination happened twice; two were extracted in the Pediatrics Emergency Unit and six by rigid bronchoscopy under general anesthesia, right source bronchus in four and left main bronchus in two. No complications occurred and all patients were discharged. Comentary: low incidence pathology. Bimodal distribution with peaks at eight months and eight years old, at home and predominantly organic material. High participation of adults without low childcare habits who came from low income sectors may have influenced the episodes. The subsequent confirmation asphyxia syndrome with suction occurred in 9 cases. Physical examination and imaging were useful. Manoeuvres to unblock the airway were ineffective. Surgical extraction in the OR with rigid bronchoscope continues to be the prevailing action. No immediate morbidity and mortality was recorded after the episode. We must insist on the dissemination of preventive measures among parents and caregivers.

Urticaria febril en la urgencia.: ¿Siempre una enfermedad benigna? / Febrile hives in the Emergency Unit: Is it always a benign condition?

Introducción: la urticaria es motivo frecuente de consulta en la urgencia pediátrica. Debe considerarse como un signo clínico y no una enfermedad en sí misma. Puede ser provocada por alimentos, agentes físicos, fármacos, toxinas, y picaduras de insectos. Las enfermedades infecciosas, en general virales, también son causa frecuente de urticaria. En ocasiones, puede corresponder a una enfermedad de origen bacteriano, de diferentes grados de severidad. Objetivo: presentar dos casos clínicos asistidos en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell con urticarias febriles, expresión de una enfermedad infecciosa bacteriana. Discusión: uno de los objetivos más importantes en la asistencia inicial es determinar el grado de urgencia de la atención, aplicando un sistema de categorización sistematizado “triage” lo que permite establecer si existe riesgo vital y necesidad de tratamiento inmediato, independiente de la causa que lo provoca. Ambos casos clínicos presentaban una infección bacteriana que se manifestó inicialmente como una urticaria febril. En el primer caso se confirmó al diagnóstico de infección urinaria en un paciente sin riesgo vital inmediato. En el segundo niño la urticaria se presentó en un paciente grave con afectación sistémica que posteriormente se focaliza como una osteoartritis de cadera. Conclusión: la urticaria en la infancia suele ser considerada una enfermedad benigna. En ocasiones puede ser la manifestación inicial de una enfermedad infecciosa grave. Las infecciones severas deben ser consideradas en la evaluación de un niño que se presenta con urticaria, fundamentalmente si se acompaña de fiebre.

Introduction: hives are frequent cause of consultation in pediatric emergency. It should be considered a clinical sign and not a disease in itself. It can be caused by food, physical agents, drugs, toxins, and insect bites. Infectious diseases in general are also common viral cause of urticaria. Occasionally, it may correspond to a bacterial disease, with different degrees of severity. Objective: to present two cases of febrile hives seen in the Pediatric Emergency Department at the Pereira Rossel Hospital Center, resulting from a bacterial infectious disease. Discussion: one of the most important objectives in the initial assistance is to determine the degree of urgency of care, by applying a systematic categorization system of “triage”, which allows to establish whether it is life-threatening and needs immediate treatment, regardless of the cause it causes. Both clinical cases had a bacterial infection that initially manifested itself as a febrile urticaria. In the first case, the diagnosis of urinary tract infection in a patient not immediately life-threatening was confirmed. In the second case, hives occurred in patients with severe systemic disease which later focused as a hip osteoarthritis. Conclusion: hives in children is usually considered a benign disease. Sometimes it may be the initial manifestation of a serious infectious disease. Severe infections should be considered when evaluating a child who presents hives, mainly if accompanied by fever.

Cumplimiento y resultados de la aplicación del protocolo de abordaje de la fiebre sin foco en lactantes de 29 a 90 días en el Departamento de Emergencia Pediátrica del Centro Hospitalario Pereira Rossell / Compliance and results of applying a protocol for treatment of fever without a source in infants of 29-90 days of age at the Pediatrics Emergency Unit of the Pereira Rossell Hospital Center

Introducción: el abordaje diagnóstico y terapéutico de niños menores de 36 meses con fiebre sin foco (FSF) ha sido motivo de controversias, particularmente en el grupo 29 a 90 días de vida. Objetivos: evaluar el cumplimiento y describir los resultados del nuevo protocolo de abordaje diagnóstico y terapéutico en los niños de 29 a 90 días de vida que consultan con FSF en DEP-CHPR. Material y métodos: se realizó un estudio transversal, descriptivo retrospectivo, en el que se incluyeron los niños entre 29 y 90 días que consultan con FSF en el DEP-CHPR, entre el 1 de octubre de 2012 y el 30 de setiembre de 2013. Resultados: en el período analizado hubo 134 consultas de niños entre 29 a 90 días de vida por FSF. Cumplieron la pauta 99 (74%). Los diagnósticos al egreso fueron: fiebre sin foco evidente 82 (61%), infección respiratoria aguda viral 23 (17%), meningitis viral y/o encefalitis 11 (8%), infección urinaria 8 (6%), gastroenteritis 4 (3%), meningoencefalitis aséptica 2 (1,5%), otitis media 2 (1,5%), meningoencefalitis aguda supurada 1 (0,75%), exantema viral 1 (0,75%). En los pacientes que presentaron infecciones graves se cumplió la pauta en 20 de 22 pacientes (90%). La principal causa de no cumplimiento fue no realizar los estudios según pauta en 20 (57%). Conclusiones: se detectó un porcentaje aceptable de cumplimiento del nuevo protocolo, la no adherencia estuvo dada fundamentalmente en la no realización de los estudios pautados. El rendimiento en la detección de EBI, infecciones virales graves y bacteriemia fue bueno.

Introduction: diagnostic and therapeutic approach of children younger than 36 months with fever without a source has been controversial, particularly in those between 29 and 90 days of age who consult at the Pediatrics Emergency Unit Emergency Unit of the Pereira Rossell Hospital Center. Method: a transversal, descriptive, retrospective study was conducted, including children between 29 and 90 days who consulted for fever without a source at the Pediatrics Emergency Unit Emergency Unit of the Pereira Rossell Hospital Center between August 1, 2012 and September 30, 2013. Results: during the time of the study, there were 134 children between 29 and 90 days who consulted for fever without a source. Ninety nine of them (47%) meet the requirements. Diagnosis upon release were: fever without evidence of focus 82 (61%), acute viral respiratory infection 23 (17%), viral meningitis and/or encephalitis 11 (8%), urinary tract infection 8 (6%), gastroenteritis 4 (3%), aseptic meningoencephalitis 2 (1.5%), otitis media 2 (1.5%), acute suppurative meningoencephalitis 1 )0.75%), viral exanthema 1 (0.75). When patients presented severe infections the recommendations were followed in 20 out of 22 patients (90%). The main cause for non-fulfilment was failing to ask for exams according to recommendations in 20 (57%).