¿Se debe ser más intervencionista en urgencias con las convulsiones febriles atípicas? Experiencia en un hospital terciario durante tres años / Should a more interventionist approach be taken in A&E departments with atypical febrile seizures? Three years’ experience in a tertiary hospital

Introducción. Se han relacionado las convulsiones febriles atípicas (CFA) con una mayor incidencia de patología grave del sistema nervioso central (SNC). Estudios recientes muestran una disminución de la prevalencia de algunas de estas enfermedades, hecho que podría modificar su manejo. Objetivos. Determinar la prevalencia de patología grave del SNC en pacientes atendidos en urgencias por CFA y detectar diferencias con los pacientes con CFA no asociada a patología grave. Pacientes y métodos. Estudio retrospectivo mediante revisión de historias clínicas de los pacientes con diagnóstico de CFA entre noviembre de 2008 y noviembre de 2011. Resultados. Se incluyen 231 episodios de CFA (223 pacientes), con una edad media de 1,7 años (p25-75 = 1,2-2,3 años), 133 (57,6%) de los cuales eran varones. Doce pacientes (5,2%; IC 95% = 2,7-8,9) recibieron el diagnóstico de patología grave del SNC. En los pacientes con patología grave del SNC, la CFA es en la mayoría de las ocasiones el primer episodio (91,7% frente a 63%; p = 0,036), presenta más de un criterio diagnóstico (50% frente a 15,1%; p = 0,007), es más frecuente la convulsión focal (50% frente a 12,8%; p = 0,003) o el estado epiléptico (25% frente a 5,9%; p = 0,041) y los pacientes presentan alteración de la consciencia persistente posterior al episodio (66,7% frente a 31,5%; p = 0,002). Conclusiones. Dado que la prevalencia de patología grave del SNC en pacientes con CFA es baja, no se recomienda la realización rutinaria de pruebas complementarias ni el ingreso. Determinadas características del episodio aumentan la probabilidad de que la CFA sea la manifestación de una patología grave del SNC (ser un primer episodio, presentar más de un criterio diagnóstico de CFA y tratarse de una convulsión focal o estado epiléptico), por lo que deberían tenerse en cuenta en el manejo del paciente (AU)

Introduction. Atypical febrile seizures (AFS) have been related with a higher incidence of severe pathologies of the central nervous system (CNS). Recent studies show a reduction in the prevalence of some of these diseases, a fact that could affect their management. Aims. To determine the prevalence of severe pathologies of the CNS in patients treated for AFS in A&E departments and to detect any differences between these and patients suffering from AFS that is not associated to any severe pathology. Patients and methods. A retrospective study was conducted by reviewing the medical records of patients diagnosed with AFS between November 2008 and November 2011. Results. Altogether, the sample consisted of 231 episodes of AFS (223 patients), with an average age of 1.7 years (p25-75 = 1.2-2.3 years), 133 (57.6%) of whom were males. Twelve patients (5.2%; 95% CI = 2.7-8.9) were diagnosed with a severe pathology of the CNS. In patients with a severe pathology of the CNS, AFS is on most occasions the first episode (91.7% versus 63%; p = 0.036) and more than one diagnostic criterion is present (50% versus 15.1%; p = 0.007). Moreover, focal seizures (50% versus 12.8%; p = 0.003) or epileptic status (25% versus 5.9%; p = 0.041) are more common, and patients present altered levels of awareness that persist after the episode (66.7% versus 31.5%; p = 0.002). Conclusions. Given the fact that the prevalence of severe pathology of the CNS in patients with AFS is low, carrying out complementary tests or admission to hospital on a routine basis are not recommended. Certain characteristics of the episode increase the likelihood of AFS being the manifestation of a severe pathology of the CNS (being a first episode, presenting more than one diagnostic criterion for AFS and being a focal seizure or epileptic status), and should therefore be taken into account in the management of the patient (AU)

[Should a more interventionist approach be taken in A and E departments with atypical febrile seizures? Three years' experience in a tertiary hospital]. / Se debe ser más intervencionista en urgencias con las convulsiones febriles atípicas? Experiencia en un hospital terciario durante tres años.

INTRODUCTION: Atypical febrile seizures (AFS) have been related with a higher incidence of severe pathologies of the central nervous system (CNS). Recent studies show a reduction in the prevalence of some of these diseases, a fact that could affect their management. AIMS. To determine the prevalence of severe pathologies of the CNS in patients treated for AFS in A and E departments and to detect any differences between these and patients suffering from AFS that is not associated to any severe pathology. PATIENTS AND METHODS: A retrospective study was conducted by reviewing the medical records of patients diagnosed with AFS between November 2008 and November 2011. RESULTS: Altogether, the sample consisted of 231 episodes of AFS (223 patients), with an average age of 1.7 years (p25-75=1.2-2.3 years), 133 (57.6%) of whom were males. Twelve patients (5.2%; 95% CI=2.7-8.9) were diagnosed with a severe pathology of the CNS. In patients with a severe pathology of the CNS, AFS is on most occasions the first episode (91.7% versus 63%; p=0.036) and more than one diagnostic criterion is present (50% versus 15.1%; p=0.007). Moreover, focal seizures (50% versus 12.8%; p=0.003) or epileptic status (25% versus 5.9%; p=0.041) are more common, and patients present altered levels of awareness that persist after the episode (66.7% versus 31.5%; p=0.002). CONCLUSIONS: Given the fact that the prevalence of severe pathology of the CNS in patients with AFS is low, carrying out complementary tests or admission to hospital on a routine basis are not recommended. Certain characteristics of the episode increase the likelihood of AFS being the manifestation of a severe pathology of the CNS (being a first episode, presenting more than one diagnostic criterion for AFS and being a focal seizure or epileptic status), and should therefore be taken into account in the management of the patient.

Análisis de los motives de derivación a un servicio de urgencias pediátricas / Analysis of the reasons for referral to a pediatric emergency department

Objetivo. Revisar los motivos y las características de las derivaciones de pacientes a un Servicio de Urgencias Pediátricas de un hospital de tercer nivel Método. Estudio retrospectivo de los informes de derivaciones y de los informes de urgencias de 250 pacientes remitidos a nuestro centro en un período de 15 días del mes de abril de 2001. Se considera idónea la derivación de los casos que se tratan de una urgencia hospitalaria (emergencia vital o necesidad de utilización de medios diagnósticos o terapéuticos no disponibles en Atención Primaria). Resultados. El 40% de los niños derivados son menores de 2 años, y el 31% tienen entre 2 y 6 años. Predomina el sexo masculino (57.2%). El 74 % son derivados por su médico habitual. Los motivos más frecuentes de derivación son la solicitud de exploraciones complementarias (24.4%) y la presencia de fiebre (14.4%). En el 58.8% de los casos consta orientación diagnóstica del médico que efectúa la derivación. Al 90% de los pacientes derivados se les realiza lo que se solicitaba. La derivación se consideró adecuada en el 74.8% de los casos, aunque un 50% de éstas podían haberse solucionado en los centros emisores. El porcentaje de adecuación aumenta al 83.5% si la derivación es realizada por el pediatra habitual (p<0.05). Conclusiones. Un motivo importante de derivación es la realización de exploraciones complementarias. Existe un buen criterio a la hora de derivar. La remisión por parte de los facultativos no pediatras y por los pediatras no habituales del paciente disminuye la adecuación de la derivación (AU)

Objective. To review the reasons and characteristics of the referrals made to the pediatric emergency department of a third-level hospital. Method. Retrospective study of the referral information and the clinical records of 250 patients that were sent to our centre during a 15-day period in the moth of April of 2001. The referral was considered appropriate if it was a hospital emergency (defined as vital emergency or need for therapeutic or diagnostic procedures not available in primary care). Results. Forty percent of the referred children were younger than 2 years of age, and 31% were between 2 and 6 years of age. There was a slight male predominance (57.2%). Seventy-four percent of the patients were referred by their primary physician. The most frequent reasons for referral were the request for diagnostic procedures (24.4%) and the presence of fever (14.4%). A preliminary diagnosis was specified by the referring physician in 58.8% of the cases. In 90% of the referred patients, the tests requested were performed by the emergency department. The referral was considered appropriate in 74.8% of the cases, although 50% of the patients could have been managed by the referring centres. The percentage of referral adequacy increases to 83.5% if the referral is made by the primary physician (p<0.05). Conclusions. An important reason for referral is the request for a diagnostic procedure. The reasons for referral are appropriate in most cases. The referrals made by health-care workers other than pediatricians, and those made by non-primary pediatricians are less adequate (AU)