[Severe thoracic trauma: review of 39 cases]. / Traumatismos torácicos graves. Revisión de 39 casos.

OBJECTIVE: To study the incidence and types of severe thoracic trauma in a cohort of pediatric polytrauma patients, compare cardiac contractility between patients with elevated troponin T levels and those with abnormal electrocardiogram (EKG) findings, and to analyze the value of thoracic computed tomography (CT) scan as a first investigation in patients with suspected thoracic trauma. MATERIAL AND METHODS: We performed a 5-year retrospective study in a cohort of trauma patients with an injury severity score of >or=25. Thoracic trauma included pulmonary contusion, hemopneumothorax, large-vessel injury, myocardial contusion, and rib fracture. In all patients, EKG and determination of troponin T were performed at admission. Echocardiogram was performed in patients with troponin T levels>0.035 U/L (except in two patients, because the technique was not available) and abnormal EKG findings. A thoracic CT scan was performed in unconscious patients or when thoracic trauma was clinically suspected, as well as a simple thorax X-ray in the following 24 hours. RESULTS: Among 209 multiple-trauma patients, thoracic injuries where detected in 39 patients. The most frequent injury was pulmonary contusion. Echocardiogram was performed in 10 patients with high troponin levels, with abnormal findings in eight patients. The six patients with EKG alterations also had high troponin levels and pathological findings on echocardiogram. Thoracic CT scan was performed in 81 patients, with abnormal findings in 36 patients. Thoracic lesions were observed in simple X-ray in three patients who had not undergone CT scan. CONCLUSIONS: The most frequent thoracic trauma was pulmonary contusion. The results of echocardiogram were abnormal in 80 % of the patients with high troponin levels who underwent this examination. Thoracic CT scan was highly useful in suspected thoracic trauma.

[Management of pediatric multiple trauma patients. Perspective of the pediatric intensive care unit]. / Asistencia al paciente politraumatizado. Realidad actual desde la perspectiva de las unidades de cuidados intensivos.

OBJECTIVE: To study the epidemiology and management of pediatric trauma patients as well as the organizational, human and technical resources dedicated to these children from the perspective of the pediatric intensive care unit (PICU). MATERIAL AND METHODS: A standardized data collection form was sent to 43 PICUs in Spain. Items inquired about the existence of training courses, trauma clinical practice guidelines and trauma registers, and which physician was in charge of trauma patients. Data on casuistics, the age of trauma patients, and the availability of human and technical resources, were also recorded. RESULTS: Twenty-four PICUs completed the questionnaire. The PICU physician was responsible for trauma patient care in 66% of the hospitals. No training courses were available in 59% of the hospitals. No trauma register was available in 62% of the hospitals. Trauma patients represented 11% of PICU admissions, and most patients were aged up to 14 years old. An anesthetist was always at the hospital in 100% of the hospitals. A radiologist and traumatologist were always at the hospital in 91%, a neurosurgeon in 66% and a pediatric surgeon in 50%. The remaining surgical and medical specialties were on call. Continuous intracranial pressure monitoring was available in 87% of the PICUs, jugular venous saturation monitoring in 54% and continuous electroencephalogram and transcranial Doppler ultrasound in 50%. Computed tomography and ultrasound were available at all times in all hospitals. Magnetic nuclear resonance and echocardiography were available at all times in 44% of the hospitals, and arteriography in 42%. CONCLUSION: In Spain, the organization of pediatric trauma management is based on pediatric teams under the supervision of a PICU physician. Some hospitals show a lack of technical and human resources. Therefore, the minimum criteria required to consider a hospital as a pediatric trauma center should be established. Trauma training courses are required.

[Critical care helicopter transport. Report of 224 cases]. / Transporte en helicóptero del paciente crítico. Revisión de 224 casos.

OBJECTIVE: To report a 5-year experience of pediatric helicopter transport and describe its characteristics, the composition of the team, its indications and the advantages of air versus ground transport. METHODS: A total of 224 flights over a 5-year period were retrospectively analyzed. The team was composed of a pediatrician and a pediatric nurse from the Pediatric Department of Hospital Sant Pau and was available 365 days per year from sunrise to sunset. The helicopters belonged to the Royal Automobile Club of Catalonia and were coordinated by the Emergency Medical Service. The area covered was Catalonia and Andorra. The number of patients, age, sex, diagnosis, and response and stabilization times were recorded. RESULTS: There were 220 patients (139 males and 81 females). Six patients died in the primary hospital before transport. Seven flights were canceled because of adverse weather, engine breakdown, or family refusal. Three twin transportations were performed. A total of 214 patients were transported in 224 flights. The mean times (in minutes) were: from emergency call to takeoff: 15; flight time: 39; between landing to the emergency room: 10. The mean stabilization time was 42 min. CONCLUSIONS: Helicopter transportation of critically-ill children by specialist teams of pediatricians and nurses shortens response time in isolated areas with poor transport. The lower number of accelerations and vibrations of the helicopter provides greater stability during transport, especially in trauma patients. Both transport models, air and ground, should be complementary.

[Comparative study of the causes of severe trauma in 1990 and 1998]. / Estudio comparativo de las causas de los traumatismos graves en el año 1990 y en el año 1998.

OBJECTIVES: To investigate the epidemiology of severe trauma in pediatric patients and to analyse the variations that occurred along the time. METHODS: Patients aged less than 16 years old admitted in 1990 and 1998 in our intensive care unit of Sant Pau Hospital with diagnosis of trauma were included. The different causes of accidents regarding age, kinf of lesion and admission type were investigated. The variations observed between the two years were compared. RESULTS: The 12.5% of 88 patients admitted in 1990 were aged less than two years, 36.6% were aged between two and eight years old and 48.8% between eight and fifteen years. Pedestrians were the main cause of accident with 38.37% followed by precipitation in 27.90% and car accident with 24.26%. In 1998, 3.03% of 66 patients who were admitted had less than two years, 28.78% were aged between two and eight years and 68.18% between eight and fifteen years old. The precipitation was the main cause of accident and occurred in 24.24%. Motorbike, car and bicycle accident was observed in 18.18%, 16.16% and in 15.15% respectively. Cranial traumathism was the most important lesion in both years, representing 75% in 1990 and 66% in 1998. CONCLUSIONS: A decrease of accidents in pediatric patients aged less than eight years and an increase of them in patients with age between eight and fifteen years has been observed. Also a decrease in pedestrians and car accidents has been observed while a dramatic increase of motorbike accidents and bicycle accidents appeared. The cranial thraumathism was the most important lesion observed in both years.

[Prevention of complications in the air transport of the critically ill pediatric patient between hospitals]. / Prevención de complicaciones en el transporte interhospitalario aéreo del paciente crítico pediátrico.

OBJECTIVES: To analyze the rate of complications recorded during patient transport after applying a stabilization protocol in the sending hospital, defined by a paediatric critical patients air transport unit. MATERIAL AND METHODS: We retrospectively analyzed the transfers made by the air unit of our hospital over a 5 years period. Patients with respiratory failure, hemodynamic compromise, or neurological involvement were identified. The stabilization protocol prior to transport is described. Operations performed during stabilization period, as well as during the transfer are quantified. Complications during transport are recorded and classified into major and minor ones. RESULTS: A total of 388 patients were transferred, of which 207 had respiratory failure, 124 neurological disorders, and 102 with hemodynamic instability. During the stabilization period, 295 patients required oxygen and 161 mechanical ventilation. A total of 14 pleural drains, 397 peripheral lines and 97 central lines were placed. Vasoactive drugs were administered on 92 occasions and anticonvulsants in 41. We have performed 24 cardiopulmonary resuscitation, and 2 patients died before the move, and one required surgery. Twenty major complications have been recorded during transfer (6 neurological, 13 hemodynamic, and 1 respiratory), and 69 minor complications (14 neurological, 29 hemodynamic and 26 respiratory). One patient died. CONCLUSION: Compliance with defined stabilization standards led to a high rate of interventions during the preparation phase. On the other hand, a small number of complications occurred during transport: only 5.1% of the patients showed any serious complication. This low rate of complications is attributable to a correct stabilization carried out prior to transfer, and based on the standards adopted by the team.

[Pro general hospital]. / Pro Hospital General.

Trauma operative systems were created in United States to optimize polytrauma patients' treatment. These systems include prehospital polytrauma care. They determine hospital requirements to treat this kind of patients, standardize physicians' training and implement hospital registries. Initially, this system was applied only in monographic centers. However, trauma services of General Hospitals that fulfill the requirements were authorized progressively by the American Surgery Academy to fulfill this function. This is the model followed in Europe at present. Accreditation requires the qualification of the stay, with specific health care resources and a detailed trauma program. The director is responsible for organizing the creation of the trauma teams, operating 24h, for teaching, protocols and guides and the coordination of pre-hospital emergency groups. In Spain, there is an extensive network of tertiary hospitals that have trauma programs and their consequent accreditation could make it possible to take advantage of their existing resources. An accreditation system should be elaborated in order to homogenize professional training in trauma emergencies and to create a National Polytraumatic Registry. The high level of technology of these hospitals and of their human resources that include all the medical, surgical specialties and central services provide an added value. Care to the trauma patients is complex and multidisciplinary. Thus, we believe that General Hospitals, within a traumas program, are the best setting to offer it with excellent conditions.