Reorganización del circuito asistencial en un Servicio de Urgencias: pequeños cambios, grandes beneficios / Reorganization of the assistance circuit in an Emergency Department: small changes, great benefits

OBJETIVO: Valorar si un cambio de circuito de los pacientes con niveles IV-V de triaje reduce el tiempo de inicio para su asistencia. MATERIAL Y MÉTODOS: Estudio descriptivo observacional. El «plan de invierno» contempla la ampliación de la zona asistencial a un área anexa al Servicio de Urgencias. En 2017, se utilizó al detectarse un aumento de demora de los pacientes con nivel IV-V, redirigiéndolos tras el triaje según el motivo de consulta. En 2018 la apertura fue sistemática, dirigiendo a todos los pacientes con nivel IV-V al espacio anexo. RESULTADOS: En 2017 el 43,2% de pacientes nivel IV esperó <60 minutos y el 65,4% con nivel V <120 minutos, respecto al 49,7% y al 76,9% en 2018 (p <0,001). En 2017 hubo un 4,9% de pacientes triados y no visitados y un 9,3% esperaron más de tres horas, respecto al 3,7% y 5,8% en 2018 (p <0,001). CONCLUSIÓN: El cambio de circuito es efectivo disminuyendo la demora en los niveles IV y V

OBJECTIVE: To know if a process change about patients with IV-V levels of triage reduces the waiting time for their assistance. MATERIAL AND METHODS: This was a descriptive observational study. The «winter plan» includes the extension of the care area to an area attached to the Emergency Department. In 2017, it was used on occasion of increases in delay of patients with level IV-V, relocating after triage according to the reason for consultation. In 2018, this area remained open. All patients with level IV-V were visited in this area. RESULTS: In 2017, 43.2% level IV patients waited <60 minutes and 65.4% level V patients <120 minutes, compared to 49.7% and 76.9% in 2018 (p <0.001). In 2017 there were 4.9% triaged and unvisited patients and 9.3% waited more than three hours, compared to 3.7% and 5.8% in 2018 (p <0.001). CONCLUSION: The new process is effective decreasing the delay in patients with levels IV-V

Mordedura de serpientes venenosas: experiencia durante 5 años / Moisonous snakebites: a five-year experience

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Factores predictores de contaminación ante un hemocultivo con crecimiento bacteriano en Urgencias / Predictive factors of contamination in a blood culture with bacterial growth in an Emergency Department

Introducción: El objetivo del estudio es identificar factores predictores de contaminación ante un hemocultivo (HC) con crecimiento bacteriano realizado en un servicio de Urgencias. Pacientes y métodos Estudio prospectivo, observacional-analítico. Se incluyen los pacientes de uno a 36 meses, febriles, sin factores de riesgo para bacteriemia, con un HC realizado en el Servicio de Urgencias entre noviembre de 2011 y octubre de 2013 en el que se observa crecimiento bacteriano. Se analizan como posibles factores predictores de contaminación: temperatura máxima, tiempo de positividad, resultado inicial de la tinción de Gram, leucocitos totales, neutrófilos totales, neutrófilos inmaduros y proteína C reactiva (PCR). Resultados: Se incluyen 169 casos. El crecimiento bacteriano del HC se considera significativo (positivo) en 30 (17,8%), y contaminado en 139 (82,2%). Todos los factores predictores analizados, a excepción de la temperatura, presentan diferencias estadísticamente significativas entre los 2 grupos. Los 3 mejores predictores de contaminación son la PCR, el tiempo de positividad y el resultado inicial de la tinción de Gram. El valor predictivo positivo de una PCR≤30mg/L, un tiempo de positividad≥16h y una tinción de Gram con morfología bacteriana considerada como probable contaminación es del 95,1, 96,9 y 97,5%, respectivamente; el valor predictivo positivo es del 100% para la combinación de los 3 factores. Se reevalúan el 8,3% de los pacientes con un HC contaminado dados de alta inicialmente a domicilio. Conclusiones: La mayoría de HC con crecimiento bacteriano son finalmente considerados contaminados. El resultado inicial de la tinción de Gram, el tiempo de positividad y el valor de la PCR permiten identificarlos precozmente. Su pronta detección permitirá reducir las repercusiones negativas derivadas de los mismos (AU)

Introduction: The aim of this study is to identify predictive factors of bacterial contamination in positive blood cultures (BC) collected in an emergency department. Patients and methods: A prospective, observational and analytical study was conducted on febrile children aged on to 36 months, who had no risk factors of bacterial infection, and had a BC collected in the Emergency Department between November 2011 and October 2013 in which bacterial growth was detected. The potential BC contamination predicting factors analysed were: maximum temperature, time to positivity, initial Gram stain result, white blood cell count, absolute neutrophil count, band count, and C-reactive protein (CRP). Results: Bacteria grew in 169 BC. Thirty (17.8%) were finally considered true positives and 139 (82.2%) false positives. All potential BC contamination predicting factors analysed, except maximum temperature, showed significant differences between true positives and false positives. CRP value, time to positivity, and initial Gram stain result are the best predictors of false positives in BC. The positive predictive values of a CRP value≤30mg/L, BC time to positivity≥16h, and initial Gram stain suggestive of a contaminant in predicting a FP, are 95.1, 96.9 and 97.5%, respectively. When all 3 conditions are applied, their positive predictive value is 100%. Four (8.3%) patients with a false positive BC and discharged to home were revaluated in the Emergency Department. Conclusions: The majority of BC obtained in the Emergency Department that showed positive were finally considered false positives. Initial Gram stain, time to positivity, and CRP results are valuable diagnostic tests in distinguishing between true positives and false positives in BC. The early detection of false positives will allow minimising their negative consequences (AU)

Tóxicos vegetales: un problema aún vigente / Poisonous plants: An ongoing problema

INTRODUCCIÓN: La consulta por ingesta de plantas es poco habitual en los Servicios de Urgencias pediátricas pero puede conllevar una elevada toxicidad. La formación sobre toxicología botánica del personal sanitario suele ser escasa y puede resultar difícil llegar al diagnóstico o establecer el tratamiento adecuado. OBJETIVO: Estudiar las características epidemiológicas y clínicas de las intoxicaciones por ingesta de sustancias vegetales con el fin de aumentar su conocimiento en el personal sanitario. MATERIALES Y MÉTODOS: Estudio descriptivo retrospectivo de los pacientes atendidos por ingesta de sustancia vegetal, entre enero del 2008 y diciembre del 2012, en el Servicio de Urgencias de un hospital materno-infantil de tercer nivel. RESULTADOS: Durante el periodo de estudio fueron atendidos 18 pacientes con ingesta de un posible tóxico vegetal. En 14 casos la ingesta se consideró potencialmente tóxica: retama, adelfa, muérdago, acebillo, judía vulgar (2), tomate de Jerusalén, ricino (2), estramonio, potus, marihuana y setas con toxicidad digestiva (2). De estos, en 10 la ingesta fue no intencionada, 2 casos pueden enmarcarse en el maltrato infantil, se produjo un caso con fin recreativo y otro con fin suicida. Destacaron por su toxicidad las ingestas de adelfa, ricino y estramonio. CONCLUSIONES: La potencial gravedad de la ingesta de sustancias vegetales y la variedad de los mecanismos de exposición al tóxico obligan al pediatra a tener presente esta posibilidad y estar preparado para su diagnóstico y manejo. Es necesario diseñar medidas preventivas específicas, como la información a las familias o la regulación de la presencia de plantas tóxicas en zonas de recreo

INTRODUCTION: A medical visit for plant ingestion is rare in the pediatric emergency services but may involve a high toxicity. The botanical toxicology training of health staff is often very limited, and it can be difficult to make a diagnosis or decide on the appropriate treatment. OBJECTIVE: To study the epidemiological and clinical characteristics of poisoning due to plant ingestion in order to increase the knowledge of the health professional. MATERIAL AND METHODS: A descriptive retrospective study was conducted on patients seen in a pediatric emergency department after the ingestion of plant substances from January 2008 to December 2012. RESULTS: During the period of study, 18 patients had ingested possible toxic plants. In 14 cases, it was considered to be potentially toxic: broom, oleander, mistletoe, butcher's-broom, and vulgar bean (2), Jerusalem tomato, castor (2), Jimson weed, potus, marijuana, and mushrooms with digestive toxicity (2). Among the potentially toxic cases, the ingestion was accidental in 10 patients, 2 cases were classed as infantile mistreatment, 1 case had recreational intention, and another one suicidal intentions. The ingestion of oleander, castor and Jimson weed had major toxicity. CONCLUSIONS: The potential gravity of the ingestion of plant substances and the variety of the exposure mechanism requires the pediatrician to bear in mind this possibility, and to be prepared for its diagnosis and management. Specific preventive information measures need to be designed for the families and for the regulation of toxic plants in playgrounds

Factores de riesgo para accidente vascular encefálico en un hospital universitario / Risk factors for cerebrovascular accident in a university hospital

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Consultas derivadas del consumo de sustancias psicoactivas en un Servicio de Urgencias Pediátrico. ¿Qué gasto sanitario representan? / Consultations derived from consumption of psychoactive substances in a Pediatric Emergency Service. What healthcare costs do they represent?

Introducción. Los cambios durante la adolescencia pueden desencadenar conflictos y derivar en conductas de riesgo evitables que requieran atención en un Servicio de Urgencias Pediátrico (SUP), como el consumo de sustancias psicoactivas. El objetivo del estudio es determinar qué gasto sanitario representan estas consultas. Métodos. Estudio descriptivo-observacional, en SUP de tercer nivel. Se incluyen las consultas de todos los adolescentes (12-18 años) durante el año 2012 por clínica secundaria al consumo de sustancias psicoactivas con finalidad recreativa. Se valoran los siguientes recursos sanitarios: transporte en ambulancia, gasto por consulta, exploraciones complementarias, tratamiento y hospitalización. Resultados. Se incluyen 91 consultas (0,8% de las generadas por adolescentes) que representan 7.189€. 65 pacientes llegan en ambulancia (6.500€). A 50 se les realiza bioquímica básica en sangre (294€); a 67, tóxicos en orina (131,3€) y a 55, niveles de etanol en sangre (107,8€). A 38 pacientes se les administra suero terapia (26,6€) y a 2, analgesia (1,56€). 5 pacientes se hospitalizan un día (950€). El gasto total generado en 2012 es de 15.200€ (media: 167€/paciente). Discusión y conclusiones. Las consultas por consumo de sustancias psicoactivas representan una pequeña proporción de las originadas por adolescentes, pero el coste económico es elevado, por lo que incidir en las medidas preventivas para evitar los efectos negativos de las sustancias psicoactivas, permitiría disminuir el consumo de recursos sanitarios (AU)

Introduction. Changes during adolescence may originate conflicts and some avoidable risk behaviors, such as psychoactive substances consumption, which may require attention at an Emergency Deparrment (ED). The aim of this study is to determine which spending represents these consultations. Methods. Descriptive-observational study, in an ED in a Pediatric tertiary hospital. Adolescents (12-18 years) who consult in 2012 with secondary symptoms to use of psychoactive substances for recreational purpose are included. We consider: ambulance transport, consultation at ED, complementary tests, treatment and hospitalization. Results. 91 consultations are included (0.8% of those generated by adolescents) which mean 7,189€. 65 patients arrive by ambulance (6,500€). 50 patients need to determine basic chemistry (294€), in 67 patients toxics in urine are determined (131.3€) and 55 require blood ethanol levels determination (107.8€). 38 patients receive intravenous fluid therapy (26.6€) and 2, intravenous analgesia (1.56€). 5 patients are hospitalized (950€). The overall costs generated in 2012 is 15,200€ (average: 167€/patient). Discussion and conclusions. Consultations for psychoactive substance consumption represent a small proportion of those caused by teenagers. However, the economic cost is high, so the impact of preventive measures to avoid negative effects of psychoactive substances, could also help reducing the healthcare resources (AU)

¿Ha aumentado la presencia de los padres durante los procedimientos invasivos en urgencias en los últimos años? / Has the presence of parents during invasive procedures in the emergency department increased in the last few years?

INTRODUCCIÓN: En los últimos años los padres están adquiriendo un protagonismo cada vez mayor en los servicios de urgencias pediátricos (SUP), manifestando su deseo de presenciar los procedimientos invasivos (PI) realizados a sus hijos. OBJETIVOS: 1) Comparar la presencia de los padres durante los PI en SUP españoles entre 2008 y 2012; 2) comparar los argumentos para restringir la presencia y los problemas derivados; y. 3) conocer si ha cambiado la opinión del personal sanitario. METODOLOGÍA: Estudio descriptivo multicéntrico comparativo. En 2008 y 2012 se envían 42 encuestas vía correo electrónico a los responsables de SUP españoles, incluyéndose en el estudio los que responden en ambos periodos. RESULTADOS: Veintidós hospitales participan en el estudio. La presencia de los padres en los SUP espa˜noles aumenta entre 2008 y 2012 para todos los PI, significativamente en la analítica sanguínea y en el sondaje vesical. En 2012 los responsables argumentan menos frecuentemente el nerviosismo de los niños, la ansiedad de los padres y el temor del personal a un peor rendimiento para restringir la presencia. En ambos periodos los problemas son ocasionales, disminuyendo el peor comportamiento de los niños. Según los responsables el acuerdo del personal sanitario no ha cambiado en estos años. CONCLUSIONES: La presencia de los padres durante los PI en los SUP ha aumentado en los últimos 4 a˜nos, aunque es aún escasa durante los procedimientos más invasivos. Los responsables argumentan menos problemas conductuales, aunque el grado de acuerdo del personal no ha cambiado, siendo necesario continuar trabajando en el tema

INTRODUCTION: In the recent years, parents are playing an important role in Pediatric Emergency Department (PED), and wish to be present when invasive procedures (IP) are performed. OBJECTIVES: 1) To compare the presence of parents during IP in PED in Spain between 2008 and 2012. 2) To compare the arguments to restrict the presence and problems arising from this, and 3) To determine whether the views of health personnel have changed on this subject. METHODOLOGY: A descriptive multicenter comparative study was conducted in 2008 and 2012. A total of 42 questionaires were sent by email to PED managers, with the responding hospitals being included in the 2 periods of the study. RESULTS: A total of 22 hospitals participated in the study. The presence of parents in the PED increased between 2008 and 2012 for all IP, significantly in the blood test and urine catheterization. In 2012, managers state that children are not so nervous, and anxiety of the parents and staff fear of a poorer performance, as an argument to restrict family presence. There were few problems during the 2 periods, with the poor behavior of the children decreasing. According to managers, the opinion of health personnel has not changed in the last four years. CONCLUSIONS: The presence of parents during the IP in the PED has increased in the last four years, although the presence is low for more invasive procedures. Managers argue the presence of fewer behavior problems to restrict family presence. The opinion of the staff has not changed in the last four years, although more studies are required on this issue

[Has the presence of parents during invasive procedures in the emergency department increased in the last few years?]. / ¿Ha aumentado la presencia de los padres durante los procedimientos invasivos en urgencias en los últimos años?

INTRODUCTION: In the recent years, parents are playing an important role in Pediatric Emergency Department (PED), and wish to be present when invasive procedures (IP) are performed. OBJECTIVES: 1) To compare the presence of parents during IP in PED in Spain between 2008 and 2012. 2) To compare the arguments to restrict the presence and problems arising from this, and 3) To determine whether the views of health personnel have changed on this subject. METHODOLOGY: A descriptive multicenter comparative study was conducted in 2008 and 2012. A total of 42 questionaires were sent by email to PED managers, with the responding hospitals being included in the 2 periods of the study. RESULTS: A total of 22 hospitals participated in the study. The presence of parents in the PED increased between 2008 and 2012 for all IP, significantly in the blood test and urine catheterization. In 2012, managers state that children are not so nervous, and anxiety of the parents and staff fear of a poorer performance, as an argument to restrict family presence. There were few problems during the 2 periods, with the poor behavior of the children decreasing. According to managers, the opinion of health personnel has not changed in the last four years. CONCLUSIONS: The presence of parents during the IP in the PED has increased in the last four years, although the presence is low for more invasive procedures. Managers argue the presence of fewer behavior problems to restrict family presence. The opinion of the staff has not changed in the last four years, although more studies are required on this issue.

[Predictive factors of contamination in a blood culture with bacterial growth in an Emergency Department]. / Factores predictores de contaminación ante un hemocultivo con crecimiento bacteriano en Urgencias.

INTRODUCTION: The aim of this study is to identify predictive factors of bacterial contamination in positive blood cultures (BC) collected in an emergency department. PATIENTS AND METHODS: A prospective, observational and analytical study was conducted on febrile children aged on to 36 months, who had no risk factors of bacterial infection, and had a BC collected in the Emergency Department between November 2011 and October 2013 in which bacterial growth was detected. The potential BC contamination predicting factors analysed were: maximum temperature, time to positivity, initial Gram stain result, white blood cell count, absolute neutrophil count, band count, and C-reactive protein (CRP). RESULTS: Bacteria grew in 169 BC. Thirty (17.8%) were finally considered true positives and 139 (82.2%) false positives. All potential BC contamination predicting factors analysed, except maximum temperature, showed significant differences between true positives and false positives. CRP value, time to positivity, and initial Gram stain result are the best predictors of false positives in BC. The positive predictive values of a CRP value≤30mg/L, BC time to positivity≥16h, and initial Gram stain suggestive of a contaminant in predicting a FP, are 95.1, 96.9 and 97.5%, respectively. When all 3 conditions are applied, their positive predictive value is 100%. Four (8.3%) patients with a false positive BC and discharged to home were revaluated in the Emergency Department. CONCLUSIONS: The majority of BC obtained in the Emergency Department that showed positive were finally considered false positives. Initial Gram stain, time to positivity, and CRP results are valuable diagnostic tests in distinguishing between true positives and false positives in BC. The early detection of false positives will allow minimising their negative consequences.

[Poisonous plants: An ongoing problem]. / Tóxicos vegetales: un problema aún vigente.

INTRODUCTION: A medical visit for plant ingestion is rare in the pediatric emergency services but may involve a high toxicity. The botanical toxicology training of health staff is often very limited, and it can be difficult to make a diagnosis or decide on the appropriate treatment. OBJECTIVE: To study the epidemiological and clinical characteristics of poisoning due to plant ingestion in order to increase the knowledge of the health professional. MATERIAL AND METHODS: A descriptive retrospective study was conducted on patients seen in a pediatric emergency department after the ingestion of plant substances from January 2008 to December 2012. RESULTS: During the period of study, 18 patients had ingested possible toxic plants. In 14 cases, it was considered to be potentially toxic: broom, oleander, mistletoe, butcher's-broom, and vulgar bean (2), Jerusalem tomato, castor (2), Jimson weed, potus, marijuana, and mushrooms with digestive toxicity (2). Among the potentially toxic cases, the ingestion was accidental in 10 patients, 2 cases were classed as infantile mistreatment, 1 case had recreational intention, and another one suicidal intentions. The ingestion of oleander, castor and Jimson weed had major toxicity. CONCLUSIONS: The potential gravity of the ingestion of plant substances and the variety of the exposure mechanism requires the pediatrician to bear in mind this possibility, and to be prepared for its diagnosis and management. Specific preventive information measures need to be designed for the families and for the regulation of toxic plants in playgrounds.

Neumoparótida, a propósito de un caso / Pneumoparotid: Presentation of a case

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Diseño de indicadores de calidad: el proceso del dolor agudo en el servicio de urgencias / Quality indicators design: acute pain process in the emergency department

La evaluación de la calidad de la asistencia prestada en los servicios de urgencias pediátricas requiere herramientas como los indicadores de calidad, que contemplen sus aspectos más importantes y permitan su monitorización. Dada la importancia del proceso del dolor en la práctica clínica, es imprescindible disponer de indicadores que nos permitan evaluarlo de forma correcta, detectar situaciones de mejora y crear programas de autoevaluación de la calidad. El objetivo de este trabajo es presentar el proceso de elaboración de indicadores de calidad para la evaluación del proceso del dolor en urgencias. El diseño de los indicadores se realiza por consenso de los autores y discusión en la Comisión del Dolor del Hospital Sant Joan de Déu a partir de los existentes en adultos y las necesidades pediátricas. La metodología para crear cada indicador es la misma que ha utilizado el Grupo de Trabajo de Definición de Indicadores de la Agencia de Evaluación y Tecnología e Investigación Médica del Servicio Catalán de Salud. Se diseñan siete indicadores: dos valoran el diagnóstico del dolor y cinco su tratamiento. La aplicación de los indicadores diseñados permitirá saber si el proceso es adecuado e implementar medidas de mejora (AU)

Title: Quality indicators design: acute pain process in the emergency department The evaluation of the quality of care delivered in the pediatric emergency department (PED) requires tools such as quality indicators, which consider the most important aspects and allow monitoring. Given the importance of the process of pain in clinical practice, it is essential to assess the current approach to the acute pain process in the PED and develop quality indicators for acute pain process evaluation. The aim of this paper is to present the process of developing quality indicators for the assessment of pain processing in the PED. The indicators’ develop is done by consensus of the authors and discussion in the Pain’s Hospital Commission. They are based on the adult’s indicators and pediatric needs. To createeach indicator we use the methodology recommended by the "Grupo de Trabajo de Definición de Indicadores de la Agencia de Evaluación y Tecnología e Investigación Médica del Servicio Catalán de Salud". Seven indicators are developed: two indicators about the pain diagnosis, and five about the pain treatment. The application of indicators developed let you know if the process is appropriate and implement improvement measures (AU)

Uso de antídotos en un servicio de urgencias pediátricas / Antidote use in a pediatric emergency department

INTRODUCCIÓN: La intoxicación es un motivo de consulta poco frecuente en un servicio de urgencias pediátricas (SUP) pero potencialmente grave. Conviene que el pediatra conozca el uso adecuado de los antídotos disponibles. OBJETIVOS: Analizar el uso de antídotos en un SUP y evaluar la idoneidad de su indicación. MATERIALES Y MÉTODOS: Estudio retrospectivo de los pacientes que consultaron, entre enero del 2008 y junio del 2012, por sospecha de intoxicación por una sustancia para la cual existe antídoto. La evaluación de la idoneidad de la indicación del antídoto se basó en las recomendaciones de la Sociedad Española de Urgencias de Pediatría. RESULTADOS: Se recogieron 1.728 consultas por sospecha de intoxicación (0,4% de las visitas). En 353 (20,4%) el tóxico implicado podía ser tratado con un antídoto. Recibieron antídoto 67 pacientes (3,9% de las consultas por sospecha de intoxicación) y se realizaron en total 69 administraciones de antídoto: oxígeno 100% (46), N-acetilcisteína (10), flumazenilo (4), naloxona (3), desferroxamina (2), vitamina K (2), bicarbonato (1) y carnitina (1). En 3 casos no existía indicación del antídoto: flumazenilo sin depresión respiratoria (2) y vitamina K tras exposición a cumarínico (1). Como efecto secundario se objetivó agitación psicomotriz tras uso de flumazenilo y disminución del tiempo de protrombina durante la infusión de N-acetilcisteína. CONCLUSIONES: La administración de antídotos en este SUP es infrecuente, mayoritariamente acorde a las recomendaciones y sin efectos secundarios importantes. Debe insistirse en la necesidad de limitar el uso de flumazenilo a los casos claramente indicados, y comprobando siempre la ausencia de contraindicaciones

INTRODUCTION: Poisoning is an infrequent cause of consultation in a pediatric emergency department (PED), but it can be potentially serious. Pediatricians should know how to use the available antidotes properly. OBJECTIVES: To analyze the use of antidotes in a PED and to assess the suitability of their indications. MATERIALS AND METHODS: A retrospective review of antidote use in a PED between January 2008 and June 2012. Inclusion criteria were age younger than 18 years and consultation for suspicious poisoning by a substance that could be treated with an antidote. The adequacy of antidote indication was based on the recommendations of the Spanish Society of Pediatric Emergencies (SSPE). RESULTS: A total of 1728 consultations for suspicious poisoning (0.4% of the total visits in the PED) were recorded. In 353 cases (20.4%) the involved poison could be treated with an antidote. Sixty-seven patients received an antidote (3.9% of consultations for suspicious poisoning), and a total of 69 administrations of an antidote were made: 100% oxygen (46), N-acetylcysteine (10), flumazenil (4), naloxone (3), deferoxamine (2), vitamin K (2), bicarbonate (1), and carnitine (1). In 3 cases there was no indication for administration: flumazenil without respiratory depression, and vitamin K following coumarin exposure. As side effects, agitation was noted after the use of flumazenil, and a decrease in the prothrombin time during infusion of N-acetylcysteine. CONCLUSIONS: The administration of antidotes in this PED is uncommon and, mainly, in accordance with the SSPE recommendations, and without serious side effects. The use of flumazenil needs to be limited to the cases with a clear indication and without any contraindication

Revisión y evaluación de las maniobras de reanimación cardiopulmonar en un servicio de urgencias / Review and evaluation of cardiopulmonary resuscitation in an emergency department

Introducción: La baja incidencia de parada cardiorrespiratoria (PCR) en niños ha motivado la creación de registros de datos que permiten valorar las medidas implantadas para poder compararlas y extraer conclusiones. El objetivo de este trabajo era conocer la experiencia del personal de un servicio de urgencias pediátricas (SUP) en la atención de las PCR, describir las medidas de reanimación cardiopulmonar (RCP) empleadas y su evaluación. Métodos: Estudio retrospectivo de las historias clínicas y del registro «tipo Utstein», durante 10 años (2001-2010), de los pacientes a quienes el personal del SUP realizó maniobras de RCP. Resultados: Se analizaron 49 episodios de RCP correspondientes a 46 pacientes (28 varones, con una mediana de edad de 2,1 años). Presentaban alguna enfermedad crónica 28 pacientes. La PCR y la etiología neurológica fueron el motivo de aviso y la causa más frecuente, respectivamente. Se encontraban en medio extrahospitalario 21 pacientes, y se iniciaron maniobras de RCP en 13. En 44 episodios se intubó al paciente, en 35 se realizó masaje cardiaco externo y en 33 se administraron fármacos. En 13 pacientes no se consiguió la recuperación de la circulación espontánea (RECE). La mediana de tiempo de RCP fue de 30 minutos, y resultó superior en los pacientes en quienes no se consiguió la RECE (45 frente a 15 min; p= 0,03). Otros 12 pacientes fallecieron durante el ingreso posterior a la PCR. El personal del SUP consideró mejorables las maniobras de RCP realizadas en 12 de los 43 episodios evaluados. Conclusiones: La realización de RCP por parte del personal del SUP es poco frecuente. La mayoría de los pacientes estaban en PCR en el momento de ser atendidos, por lo que requirieron la realización de RCP avanzada. El personal del SUP evaluó las maniobras de RCP realizadas en 43 casos, y las consideró correctas en 31, mejorables en 10 y deficientes en 2 episodios (AU)

Introduction: The low incidence of cardiac arrest (CA) in children has prompted the creation of data records that allow assessing the measures implemented for comparison and extract conclusions. The aim of this study was to determine the experience of the staff of a pediatric emergency department (PED) in the care of the CA and describe the steps used during the cardiopulmonary resuscitation (CPR) and their evaluation. Methods: A retrospective study of medical records and registration "Utstein type" of patients that PED staff performed CPR for 10 years (2001-2010). Results: We analyzed 49 episodes of CPR corresponding to 46 patients (28 male; median age 2.1 years). Chronic illness was suffered by 28 patients. CA and neurological etiology were the reason for notice and the most frequent cause respectively. They were out-of-hospital 21 patients and initiated CPR in 13. In 44 episodes the patients were intubated, in 35 external cardiac massage was performed and in 33 drugs were administered. In 13 patients recovery was not achieved spontaneous circulation (RSC). Median RCP time was 30 minutes, being higher in patients not able RSC (45 vs 15 min; p= 0.03). Another 12 patients died during hospitalization after the CA. PED staff considered improvable CPR performed in 12 of the 43 episodes that were evaluated. Conclusions: Performing CPR by PED staff is rare. Most patients were in CA at the time of being served requiring advanced CPR. PED staff evaluated CPR performed in 43 cases, considered correct in 31, improved in 10 and poor in 2 patients (AU)

Niños portadores de una válvula de derivación de líquido cefalorraquídeo: motivos de consulta, diagnósticos y consumo de recursos en el servicio de urgencias / Children with cerebrospinal fluid shunts: signs and symptoms, final diagnoses and use of health resources in the emergency department

Objetivos: Determinar los motivos de consulta en el servicio de urgencias de los niños portadores de válvula de derivación de líquido cefalorraquídeo (VDL), así como sus diagnósticos al alta, y comparar el consumo de recursos que generan con el de la población general. Métodos: Se revisan los datos referentes a la sintomatología, la actuación y el diagnóstico definitivo de todas las consultas realizadas en el servicio de urgencias por parte de los niños portadores de VDL, desde el 1 de abril de 2010 al 31 de marzo de 2011 (grupo 1). Se seleccionan todas las consultas generadas en el mismo año de un grupo de pacientes no portadores de VDL inmediatamente antes de las consultas de los portadores de VDL (grupo 2). El coste económico se valora mediante el número de consultas y las exploraciones complementarias. Resultados: Se incluyen 250 consultas de portadores de VDL, que corresponden a 99 pacientes (grupo 1). Los motivos de consulta más frecuentes son los vómitos, la fiebre y la cefalea, y los diagnósticos la infección respiratoria (22,6%) y la disfunción valvular (14%). El grupo 2 queda constituido por 250 niños, que realizan 549 consultas. Los pacientes del grupo 1 reciben más exploraciones complementarias por consulta que el grupo 2 (el 48 frente al 25%; p <0,001), y el coste económico que generan también es mayor (mediana de 77,9 frente a 70 Euros/consulta; p <0,001); este aumento está relacionado con las consultas por sintomatología potencialmente asociada a disfunción valvular. Conclusiones: Los niños portadores de VDL consultan a menudo por una sintomatología potencialmente asociada a disfunción valvular, pero ésta no se confirma en muchas ocasiones. El gasto sanitario que generan es superior al del resto de usuarios de urgencias, debido principalmente a las pruebas realizadas para descartar una disfunción valvular. Dada su baja frecuencia, es necesario desarrollar escalas clínicas que mejoren la selección de los pacientes a quienes deben realizarse estas pruebas (AU)

Objective: 1) To determine the reasons for consultation of children with cerebrospinal fluid shunts (CFS) to the emergency department (ED) and their final diagnoses. 2) To compare their use of health resources with that of general population. Methods: All children with CFS consulting for any reason to the ED from 1 April 2010 to March 31, 2011 were included (group 1). We recorded epidemiological data, symptoms, complementary examinations performed in the ED and final diagnosis of all patients. A group of children without CFS who had visited the ED immediately before a child with CFS (group 2) were selected. The use of health resources is assessed by the number of ED visits and the number of complementary examinations received by each patient. Results: Group 1 consisted of 99 patients that generated 250 visits to the ED. The most common symptoms were: vomiting, fever and headache and the most common diagnoses were acute respiratory infection (22.6%) and CFS malfunction (14%). Group 2 consisted of 250 patients that generated 549 visits to the ED. Children in group 1 received more complementary examinations per visit than children in group 2 (48 vs 25%; p <0.001). The use of health resources was higher in group 1 than in group 2 (median 77.9 vs 70 Euros/ED visit; p <0.001). This increase in cost is related to consultation for symptoms potentially linked to CFS malfunction. Conclusions: Children with CFS often consult ED with symptoms associated with CFS malfunction but in most cases malfunction is not confirmed. Children with CFS generate greater use of health resources than general population, primarily due to complementary examinations to rule out CFS malfunction. The high number of patients with no CFS malfunction makes it necessary to develop new clinical scales that improve the selection of children to undergo complementary examinations (AU)

[Antidote use in a pediatric emergency department]. / Uso de antídotos en un servicio de urgencias pediátricas.

INTRODUCTION: Poisoning is an infrequent cause of consultation in a pediatric emergency department (PED), but it can be potentially serious. Pediatricians should know how to use the available antidotes properly. OBJECTIVES: To analyze the use of antidotes in a PED and to assess the suitability of their indications. MATERIALS AND METHODS: A retrospective review of antidote use in a PED between January 2008 and June 2012. Inclusion criteria were age younger than 18 years and consultation for suspicious poisoning by a substance that could be treated with an antidote. The adequacy of antidote indication was based on the recommendations of the Spanish Society of Pediatric Emergencies (SSPE). RESULTS: A total of 1728 consultations for suspicious poisoning (0.4% of the total visits in the PED) were recorded. In 353 cases (20.4%) the involved poison could be treated with an antidote. Sixty-seven patients received an antidote (3.9% of consultations for suspicious poisoning), and a total of 69 administrations of an antidote were made: 100% oxygen (46), N-acetylcysteine (10), flumazenil (4), naloxone (3), deferoxamine (2), vitamin K (2), bicarbonate (1), and carnitine (1). In 3 cases there was no indication for administration: flumazenil without respiratory depression, and vitamin K following coumarin exposure. As side effects, agitation was noted after the use of flumazenil, and a decrease in the prothrombin time during infusion of N-acetylcysteine. CONCLUSIONS: The administration of antidotes in this PED is uncommon and, mainly, in accordance with the SSPE recommendations, and without serious side effects. The use of flumazenil needs to be limited to the cases with a clear indication and without any contraindication.