Politraumatismo del niño
ABSTRACT Los traumatismos graves provocan un tercio de la mortalidad infantil. El 30% de los fallecimientos por esta causa, que se consideran evitables, se produce pocas horas después del accidente. Para tratar de disminuir el número de fallecimientos evitables se necesita la intervención de un equipo especializado y una estrategia terapéutica óptima. El conocimiento de las características anatómicas y fisiológicas del niño es fundamental para poner en marcha tal estrategia. La atención médica comienza en la etapa prehospitalaria con la búsqueda, la valoración y el tratamiento de las dificultades vitales inmediatas. Continúa en un centro hospitalario infantil preparado para la atención de niños politraumatizados, en el que se evalúan las lesiones según un orden cronológico de gravedad decreciente. Por último, se emprende el tratamiento de todas las lesiones. Una estrategia terapéutica óptima no es posible sin la acción conjunta de todos los facultativos a cargo de la atención del paciente, bajo la dirección de un médico coordinador que, por regla general, es el especialista en reanimación. Desde el punto de vista ortopédico, las indicaciones de osteosíntesis son más amplias que de costumbre. El objetivo es poder movilizar al paciente de forma segura, evitar las complicaciones por decúbito y facilitar la colocación de vías de acceso como, por ejemplo, un tubo de drenaje torácico. La urgencia ortopédica atañe sobre todo a la columna vertebral, las fracturas abiertas de los miembros, el síndrome compartimental y las fracturas con complicaciones vasculares. Las otras fracturas pueden tratarse dentro de las primeras 48 horas, sin olvidar las fracturas menores, que pueden pasar inadvertidas y dejar secuelas que deberán tratarse posteriormente.
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ABSTRACT: The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.The Journal of trauma 09/1996; 41(3):471-5. DOI:10.1097/00005373-199609000-00014 · 2.96 Impact Factor
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ABSTRACT: Nonoperative management (NOM) of liver trauma is currently rather the rule than the exception. However, the current evidence presents subgroups of patients at higher risk for NOM failure. These patients must be treated more cautiously regarding the NOM approach. A case report of 3 polytrauma patients (Injury Severity Score > 17) with high-degree liver trauma managed nonoperatively. The first case presented is the one of a polytrauma patient with degree IV liver injury and impaired mental status. It was a high risk for NOM failure because there was an angiographically hemostasis. The second case is one of a polytrauma patient who became hemodynamically stable after the administration of 2000 ml of fluid intravenously. There was a nonoperative approach with angiography and embolization of degree IV liver injury. Despite the success of the nonoperative treatment, there was an important hepatic necrosis following embolization. The third case is one of a polytrauma patient with a degree IV hepatic injury. Success was accomplished in NOM without an angiography. Nonoperative management of liver injuries can be applied safely even in high degree hepatic trauma. In hemodynamically metastable patients or impaired mental status patients, the nonoperative approach can be applied successfully, but the trauma surgeon must be very cautious.08/2010; 3(3):289-96.
Article: Les traumatismes sévères de l'enfant[Show abstract] [Hide abstract]
ABSTRACT: Trauma are responsible for approximately 50% of the deaths of the pediatric population between 1–15 years of age. This high mortality rate, associated with frequent sequelae, leading sometimes to severe handicaps, is a major problem of public health in the developped countries. Pediatric trauma have some particularities, due to anatomical and physiological differences, and to specific injury mechanisms. Management of a patient with severe trauma is best performed by trained physicians, working in a multidisciplinary team with a two steps approach: 1) emergency rapid clinical assessment and ressucitation, 2) a secondary complete clinical evaluation associated with medical imaging, mainly based on CT scan. Head injuries are frequent and represent the main prognosis factor, mass lesions being less frequent and cerebral oedema more frequent in children, than in adult; brain swelling appears to be less frequent than initially reported. Management of head trauma has evolved in recent years, and is now largely directed towards the prevention of secondary ischemic brain injury; new monitoring devices are proposed to pursue that goal; transcranial doppler and continuous jugular vein oxygen saturation monitoring. Spinal cord injuries are rare but may be severe; cervical and spinal cord injuries without radiological abnomality (SCIWORA) appear to be more frequent than in adult. Most often, abdominal plain viscera injuries are treated with a conservative non operative approach. Among chest injuries, pulmonary contusion is the most frequent, with a favorable outcome in most cases within 3–4 days. Child abuse must be suspected in any case where there is no clear injury mechanism or when there is a discrepancy between the severity of the injury and the alleged mechanism.Archives de Pédiatrie 05/1997; 4(5):443-459. DOI:10.1016/S0929-693X(97)86673-0 · 0.41 Impact Factor