Atención a las víctimas por ataque terrorista con explosivos / Clinical management of terrorist bomb explosions

El 11 de marzo de 2004 se produjo en Madrid un atentado terrorista haciendo explosionar 10 bombas en cuatro vagones de ferrocarril. De forma inmediata fallecieron 177 personas sumándose 14 fallecimientos posteriores en el ámbito hospitalario. Nuestro objetivo es mostrar nuestra experiencia en este tipo de incidentes. La mayoría de las víctimas llegaron al Servicio de Urgencias entre las 8:00 y las 11:00 h. De un total de 312 pacientes atendidos en nuestro Centro, 12 casos fueron asistidos en el Hospital Infantil. La edad media de los pacientes fue de 16 años (rango = 14-21). Diez pacientes fueron hospitalizados. Dos pacientes fueron considerados críticos precisando ingreso en la unidad de cuidados intensivos (presentaban un ITP de 5). Las diferentes lesiones detectadas fueron: perforaciones timpánicas (81%), lesiones de partes blandas con cuerpos extraños (36%), lesiones oculares (27%), lesiones musculoesqueléticas (27%) traumatismos torácicos (18%), traumatismo craneoencefálico severo en un caso y contusión pulmonar bilateral (blust lung injury) más traumatismo abdominal en otro. Todos los pacientes sobrevivieron, si bien presentaron secuelas traumatológicas, oculares, auditivas y todos precisaron apoyo psiquiátrico postatentado. Del análisis de estos resultados se desprende que las lesiones más frecuentes son las derivadas de la onda expansiva en un compartimiento cerrado siendo las lesiones timpánicas, oculares y de partes blandas las más frecuentes. La logística hospitalaria así como el entrenamiento personal y de grupos en los programas de asistencia al trauma pediátrico (AITP) son cruciales para enfrentarse a situaciones excepcionales de múltiples víctimas (AU)

At 07:39 on 11 March 2004 terrorist bomb explosions ocurred in 4 trains in Madrid killing 177 people instantly and 14 more later in the hospital. This report describes the organization, clinical management and patterns of injuries in casualties who were taken to our chilren patients were taken to the Gregorio Marañon hospital and 12 to the children´s one. The mean age was 16 years (14-21), Two of them were critically ill and needed intensive care (ITP 5). Tympanic perforations occurred in 81% victims with moderate to severe trauma, shrapnel wounds in 36% and eye lesions in 27%. Among critically ill patients blast lung injury, cranial and abdominal trauma were the most important lesions. Training in AITP courses and hospital logistics were essential in clinical management of these casualties (AU)

[Clinical management of terrorist bomb explosions]. / Atención a las víctimas por ataque terrorista con explosivos.

At 07:39 on 11 March 2004 terrorist bomb explosions ocurred in 4 trains in Madrid killing 177 people instantly and 14 more later in the hospital. This report describes the organization, clinical management and patterns of injuries in casualties who were taken to our chil-patients were taken to the Gregorio Marañon hospital and 12 to the children's one. The mean age was 16 years (14-21), Two of them were critically ill and needed intensive care (ITP 5). Tympanic perforations occurred in 81% victims with moderate to severe trauma, shrapnel wounds in 36% and eye lesions in 27%. Among critically ill patients blast lung injury, cranial and abdominal trauma were the most important lesions. Training in AITP courses and hospital logistics were essential in clinical management of these casualties.

[Bilateral femoral cephalic osteonecrosis in a human immunodeficiency virus-infected child taking HAART]. / Nécrose céphalique bilatérale du fémur chez un enfant infecté par le virus de l'immunodéficience humaine soumis à une multithérapie antirétrovirale.

Musculoskeletal complications are uncommon in HIV-infected patients. In adults, one manifestation is osteonecrosis which can be associated with risk factors such as alcohol consumption, smoking or use of corticosteroids. Such risk factors are rare in children. Over the last decade musculoskeletal complications have been observed in patients with advanced-stage disease or whose immune system has been reconstituted with highly active antiretroviral therapy (HAART). This complication has been reported in adults but to date not in children. We present the case of a 5-year-old child with AIDS (C stage 3) who developed osteonecrosis related to the advanced stage of the illness and to HAART. No risk factors were found.

Paediatric trauma in Spain: a report from the HUGM Trauma Registry.

OBJECTIVES: To analyse the characteristics of the infant population suffering trauma in our setting. To evaluate the importance of the different aetiological mechanisms. To study the pre- and intra-hospital management of these children. To describe the relative significance of the different lesions. To establish the magnitude of paediatric trauma as a social problem in terms of morbidity and mortality. MATERIAL AND METHODS: From January 1995 to April 2002, a total of 2633 children admitted to our Centre (Hospital Universitario Gregorio Maranon) after suffering some type of injury were included in our Trauma Register. 108 variables have been analysed, including the identification of the patient, type, site and mechanism of the accident, pre-hospital care, transport, complete evaluation on admission, indices of injury severity, diagnostic tests, lesions, treatments performed and morbidity and mortality. RESULTS: The accidents were more frequent in boys than in girls (68.5 % versus 31.5 %). The predominant age group was the 12 - 15 year old group (36.8 %). There was a higher frequency of accidents in the street (37.2 %) than at home (19.4 %) or at school (13.8 %). The most frequent mechanism was a fall (35.6 %), followed by road traffic accidents (23.7 %). On admission, 14.7 % of the children had a Paediatric Trauma Score (P.T.S.) < or = 8 (n = 388). 3.8 % were considered severe multiple trauma patients, presenting an Injury Severity Score (I.S.S.) > or = 15 (n = 101). 4.2 % of the children required intensive care. The most frequent lesions were those of the locomotor system (58.1 %) and head injuries (34.9 %). Some type of surgical or orthopaedic procedure was performed under general anaesthesia in 1522 patients (57.8 %). The mean length of stay was 4.4 days (range 1 - 214 days). Sequelae of some form were detected in 36.4 % of the patients over 3 years of age. The total mortality was 0.5 % (n = 13), being 12.8 % in the group of patients with an I.S.S. > or = 15. CONCLUSIONS: Analysis of the data in our Registry has helped us to define the characteristics of the paediatric trauma population in our setting, to monitor the management of trauma in the different care levels and to develop prevention programmes. It has also enabled us to compare the results with those of other centres in terms of morbidity and mortality with the aim of identifying and correcting any possible deficiencies in the care system.

Resultado del tratamiento de las luxaciones congénitas de rodilla. A propósito de 27 casos / Result of congenital knee dislocation treatment in 27 cases

Objetivo. Con este trabajo queremos presentar nuestra experiencia en el tratamiento de las luxaciones congénitas de rodilla(LCR) y de sus anomalías asociadas, aportando nuestros resultados tanto con el manejo ortopédico como con el quirúrgico. Material y método. Realizamos un estudio retrospectivo de los casos de LCR diagnosticados y tratados en nuestro servicio entre 1990 y 2000. La serie consta de 16 pacientes (27 rodillas), 11 niñas y 5 niños (edad media 7 días) con un tiempo medio de seguimiento de 5 años (1,5-16 años). En 11 casos se afectaron ambas rodillas, siendo unilateral en los restantes 5. Siguiendo la clasificación de Ferris, 4 rodillas pertenecían al tipo I, 5 al tipo II o subluxación y las 18 restantes al tipo III. La anomalía esquelética asociada más frecuente fue la luxación congénita de cadera (LCC) (63%). El tratamiento se inició dentro de las primeras 24 horas de vida en la mayoría (63%), e inicialmente consistió en una reducción manual e inmovilización con yeso en flexión, que era cambiada progresivamente en función de la mejoría de la deformidad. La duración media del tratamiento ortopédico fue de 90 días (42-150). En 5 de las rodillas (19%) no se consiguió una reducción satisfactoria y precisaron tratamiento quirúrgico. Resultados. Para la valoración de resultados se usaron 3 parámetros, el rango de movilidad, la estabilidad y el dolor. Nueve rodillas (33%) tuvieron un resultado excelente, 12 rodillas (45%) tuvieron un resultado bueno (85%) y 6 (22%) un resultado regular. No hubo ningún resultado malo. La complicación más frecuente fue la fractura de tibia en 4 casos y la de fémur en uno. Conclusiones. El tratamiento de las LCR debe iniciarse lo más precozmente posible y posponer o simultanear el tratamiento de las patologías asociadas. El resultado funcional empeora dependiendo de la importancia de las anomalías constitucionales concomitantes

Objective. The aim of this study is to present our experience in the treatment of congenital dislocation of the knee (CDK) and associated anomalies and the results of nonoperative and surgical management. Materials and methods. A retrospective study was made of cases of CDK diagnosed and treated in our department from 1990 to 2000. The series consisted of 16 patients (27 knees),11 girls and 5 boys (mean age 7 days), with a mean fo-llow-up time of 5 years (1.5-6 years). Eleven patients had bilateral disease and 5, unilateral disease. Following the Ferris classification, 4 knees were type I, 5 were type II (subluxations),and the remaining 18 were type III. The most frequent associated skeletal anomaly was congenital hip dislocation (CDH) (63%). Treatment began in the first 24 hours of life in most patients (63%) and consisted initially in manual reduction and immobilization with a flexion cast that was changed as the deformity improved. The mean durationof nonoperative treatment was 90 days (42-150 days). In 5 knees (19%), the reduction was unsatisfactory and surgicaltreatment was required. Results. Results were evaluated using 3 parameters, range of mobility, stability and pain. Excellent results were achievedin 9 knees (33%), good results in 12 (45%), and only fair results in 6 (22%). There were no poor results. The most frequent complication was tibial fracture in 4 cases and femoral fracture in 1. Conclusions. CDK treatment should begin as soon as possibleand associated pathologies should be treated at the same time or later. The functional outcome worsens in relation to concomitant constitutional anomalies

[Impact of formation programs in initial management of injured children]. / Impacto de los programas de formación en la asistencia al niño traumatizado.

INTRODUCTION: In 1997 we developed the "Pediatric Trauma Life Support Course"applied to every one who provide care for the pediatric trauma patient. Since November 1997 until December 2000, 14 courses were imparted inside of the "Comunidad de Madrid" with total number of 289 students. Thirty-eight students have been people who worked in the prehospital area inside of our Community. The aim of this paper is to determinate the possible impact of these Courses in the prehospital management of the pediatric trauma patient. MATERIAL AND METHODS: We reviewed the Pediatric Trauma Registry inputs of our hospital since January 1995 until December 2000. A total number of 2166 patients required admission in our hospital after the injuries. 495 patients which moved to our Institution by medical people and a special transport (ambulance/medical van) were enrolled. The patients were classified into two groups. In the first group were included the children admitted between 1995 to 1997 (group 1, n = 232), before we had applied our Courses and in the second group, the patients admitted between 1998 to 2000 (group II, n = 263), after The Pediatric Trauma Life Support Course was conducted. Both groups seems to be equal if we compare the age, sex and severity of the injuries. We analysed the infant orotracheal intubation in a coma patient, gastric intubation in the several trauma patient, vascular access and apply a semirigid cervical collar into a head injury. If we think that the application of these manouvers will be a good quality index of the management of these patients in the prehospital area, we compare the index of application of these variables according to the years before and after the Courses were imparted. For this pourpose we used the X2 test shows significant differences within both groups if p < 0.05. RESULTS: All paramethers analyzed were better in group II than in group I (p < 0.05). CONCLUSIONS: The results of this paper shows that the use of this program for the management of the pediatric trauma patient is going well and the assessment is doing better than few years before.

[Events related with injury severity in pediatric multiple trauma]. / Factores relacionados con la severidad en el niño politraumatizado.

AIMS: Epidemiological analysis of main factors affecting multiple trauma in children in our environment. METHODS: We reviewed the data collected from the patients (n = 2.166) admitted to our hospital because of trauma and included in our Registry from January 1995 to December 2000. Among this group 79 patients were considered severely injured trauma patients according Injury Severity Score (ISS) (ISS > 15) and selected for the study. Statistical analysis was done using chi2 and Student t test, p values under 0.01 were considered significant. RESULTS: Group gender distribution was 49 males and 30 females, age average was 9.7 years (range 0-15 years) Traffic related injuries were the leading cause of trauma in this group (77,2%). Initial triage by using the Pediatric Trauma Score allowed identifying the injury severity in 73,4% of patients (58 children obtained a PTS < or = 8). In 32,9% of the cases the patient was in coma at admission in the Emergency (Glasgow Coma Scale < or = 8, n = 26). ISS average was 23.4 (range 16-75). Most patients suffered from multiple injuries (87,3%), average of injuries number was 4,7 (range 1-9). The most frequent trauma localization was cranial trauma. Admission in the intensive care unit was necessary in 65,8% of patients, and any kind of surgical procedure was done in 35,4%. Average length of stay was 17,1 days (range 0-214 days). Injury severity was higher in automotive patients without restraining systems (I.S.S. average 27,2, mortality 16,6%). Overall mortality was 11,4% (n = 9), and 94.3% of patients presented any functional or anatomic disability. CONCLUSIONS: Traffic related injuries are the main cause of multiple trauma in children. The severity and high mortality of these injuries make imperative polytonal education systems and the use of restraining devices.

Traumatismos obstétricos ¿Un problema actual?* / Obstetric trauma. An actual issue?

Debido a los avances de la práctica obstétrica, los traumatismos neonatales han disminuido significativamente en los últimos años; sin embargo, constituyen un importante capítulo dentro de la patología neonatal. Entre 1993 y 1998 se han registrado en nuestro hospital un total de 21.375 recién nacidos vivos y se han producido un total de 309 traumatismos neonatales en 303 pacientes (1,44 por ciento). La distribución por diagnósticos ha sido: dos hematomas subcapsulares hepáticos, 105 cefalohematomas, 16 fracturas parietales, 11 hemorragias subdurales, 107 fracturas de clavícula, 10 fracturas diversas, 8 heridas incisocontusas, 25 parálisis faciales y 25 parálisis braquiales. En cuanto al mecanismo del parto, la fractura de clavícula se asoció al parto vaginal con presentación cefálica en el 50 por ciento de los casos, el cefalohematoma al fórceps en el 51 por ciento. la parálisis braquial al parto vaginal en el 44 por ciento y al fórceps en el 36 por ciento. El elevado peso al nacimiento fue un factor de riesgo para patologías como la parálisis braquial y las fracturas de clavícula. Concluimos que el traumatismo neonatal es una patología de incidencia y significación importante cuya epidemiología es necesario conocer (AU)

Premature physeal closure after tibial diaphyseal fractures in adolescents.

Seven cases of premature physeal closure secondary to diaphyseal fractures of the tibia in adolescents between 12 and 15 years of age are presented. At the time of the accidents, there was no evidence of physeal lesion in any of the patients. After 4 to 13 months of follow-up (mean, 9 months), early closure was observed in the radiologic controls of one or more physes of the affected leg: distal femoral and proximal and distal tibial in three cases, isolated distal femoral physis in three cases, and both tibial physes without femoral damage in one case. Physeal closure was always central, and there was no case of angular deformity. After 15 to 42 months of follow-up (mean, 27 months), all patients had a leg-length discrepancy in the 8- to 30-mm range (mean, 18 mm). Only one patient required surgical correction (proximal epiphysiodesis of the contralateral tibia followed by tibial lengthening). Adolescents with diaphyseal fractures of the long bones should be monitored until they have stopped growing because of the risk of developing leg-length discrepancy as a consequence of premature closure of one or more leg physis.

[Obstetric trauma. A current problem?]. / Traumatismos obstétricos. Un problema actual?

Advances in obstetric practice have decreased birth traumas in the last years, although they are still an important chapter in neonatal age. Between 1993-1998 a total of 21,375 stillborns were registered with a total of 309 birth injuries in 303 neonates (1.44%). The diagnoses were: 2 liver subcapsular hematomas, 105 cephalohematomas, 16 parietal fractures, 11 subdural hemorrhages, 107 clavicular fractures, 10 miscellaneous fractures, 8 soft tissue injuries, 25 facial nerve injuries and 25 braquial palsy. About relation between type of labor and birth trauma was found that clavicular fracture and cephalic vaginal delivery were associated in 50% of the cases, cephalohematoma and forceps in 51%, braquial palsy and vaginal delivery in 44% and forceps in 36%. High weight at birth was another risk factor for entities such as clavicular fracture and braquial palsy. We conclude that birth trauma is a pathology with a relevant incidence and their epidemiology factor had to be known.

Osteochondritis dissecans of the talus during childhood and adolescence.

Between 1985 and 1996, our Service treated 18 cases of osteochondritis dissecans of the talus in children and adolescents. The lesion is more frequent during childhood than previously thought. Different theories about the etiology of the lesion and the various treatments used are discussed. The outcome was satisfactory in most cases. We consider that, with the exception of type IV Berndt and Harty lesions, preliminary treatment should be conservative, which gave good results in our study. Surgical treatment should be reserved for patients with an unsatisfactory evolution with orthopaedic treatment, with lesions with thick sclerotic edges, or for patients with loose intraarticular fragments.

Segmentary splenectomy of the lower tip because of spontaneous rupture of a splenic hemangioendothelioma in a new-born child--a case report.

We present the first exceptional case of splenic hemangioendothelioma, an infrequent and generally asymptomatic benign vascular tumor, here triggering hypovolemic shock through spontaneous rupture of the spleen without prior injury. Conservative treatment of the spleen led us to perform a segmentary splenectomy of the lower tip with total extirpation of the vascular tumour and the acute splenic bleeding was controlled. One year later, splenic functions are normal.