Guía práctica del traumatismo abdominal en la edad pediátrica

RESUMEN El traumatismo abdominal en la edad pediátrica se considera la segunda causa de muerte después del trauma craneoencefálico. Requiere para su diagnóstico un alto índice de sospecha y su riesgo vital está condicionado por la hemorragia y la peritonitis. Con el propósito de estandarizar en una guía la conducta en Cuba en el traumatismo abdominal pediátrico, se realiza una revisión bibliográfica sobre el tema y el estudio de diferentes casuísticas del hospital pediátrico "Juan Manuel Márquez", que es centro provincial de politrauma infantil de La Habana; la guía se aprueba por consenso en la Sociedad Cubana de Cirugía Pediátrica. Las causas más frecuentes de traumatismo abdominal son: en el niño mayor los accidentes de tránsito y en el niño menor las caídas de altura. En la anamnesis es importante la cinemática del trauma y la superficie de impacto. El examen físico debe ser evolutivo y en la evaluación inicial debe identificarse el riesgo vital. En el diagnóstico por imágenes se considera esencial la tomografía contrastada la que en nuestro centro se reserva para casos con dudas diagnósticas y de evolución no satisfactoria, la ecografía tiene gran utilidad. Se prioriza el tratamiento no quirúrgico en el trauma cerrado con ruptura de víscera maciza, siempre que exista estabilidad hemodinámica. Actualmente la cirugía de control de daños ha demostrado mejorar la sobrevida en pacientes con lesiones abdominales complejas y exanguinantes.

ABSTRACT Abdominal trauma in pediatric age is considered the second leading cause of death after traumatic brain injury. It requires for its diagnosis a high index of suspicion and its vital risk is conditioned by hemorrhage and peritonitis. With the purpose of standardizing in a guide the behavior in Cuba of pediatric abdominal trauma, a bibliographic review is carried out on the subject and the study of different casuistries of "Juan Manuel Márquez" Pediatric Hospital, which functions in turn as a provincial center of children's polytrauma of Havana; the guide is approved by consensus in the Cuban Society of Pediatric Surgery. The most frequent causes of abdominal trauma are: in the older children, traffic accidents and in the younger children falls from heights. In the anamnesis, the kinematics of the trauma and the impact surface are important. The physical examination should be evolutionary and the initial assessment should identify the life risk. In the diagnosis by images is considered essential the contrasted tomography which in our center is reserved for cases with diagnostic doubts and unsatisfactory evolution; ultrasound is very useful. Non-surgical treatment is prioritized in closed trauma with solid viscera rupture, provided that hemodynamic stability exists. Currently, damage control surgery has been shown to improve survival in patients with complex and exanguinating abdominal injuries.

Análisis de la frecuencia de pacientes politraumatizados en accidentes en motocicleta en la población pediátrica atendida en el Hospital Pediátrico de Sinaloa entre los años 2015 y 2017 / Analysis of the frequency of polytraumatized patients in motorcycle accidents in the pediatric publication attended in the Pediatric Hospital of Sinaloa between the years 2015 and 2017

Resumen: Objetivos: Determinar la frecuencia de los pacientes pediátricos politraumatizados involucrados en accidentes por motocicleta atendidos en el Hospital Pediátrico de Sinaloa entre los años 2015 y 2017, así como determinar la frecuencia de traumatismos craneoencefálicos, lesiones torácicas, abdominales, en extremidades, días de estancia hospitalaria y mortalidad. Material y métodos: La población seleccionada fueron pacientes menores de 18 años de edad que se encontraron involucrados en accidentes de motocicleta atendidos en el Hospital Pediátrico de Sinaloa en un período comprendido entre el 1o de Enero de 2015 al 31 de Diciembre de 2017. Resultados: El género más afectado fue el masculino, con edad más frecuente de 14 años, los accidentes ocurrieron con mayor frecuencia los Viernes y Sábados en horario nocturno. Julio fue el mes con mayor índice de accidentes. La cantidad de accidentes se incrementó cada año. La mayoría de los lesionados fueron pasajeros, 98.4% no utilizó equipo de seguridad, la lesión más común fue el traumatismo craneoencefálico, seguido de lesiones en extremidades inferiores, superiores, traumatismo torácico y la menos común, el traumatismo abdominal. Discusión: Hay un incremento progresivo en los accidentes en motocicleta donde se involucra la población pediátrica, el uso de casco es casi nulo, la mayoría de los pacientes presentó traumatismo craneoencefálico, este estudio sirve para analizar el panorama actual, así como ser la base de estudios posteriores y realizar más campañas para la prevención de accidentes en motocicleta y fomentar el uso de casco en pacientes pediátricos.

Abstract: Objectives: Determine the frequency of polytraumatized pediatric patients involved in motorcycle accidents treated at the Pediatric Hospital of Sinaloa between 2015 and 2017, as well as to determine the frequency of traumatic brain injuries, thoracic, abdominal, limb injuries, days of hospital stay and mortality. Material and methods: The selected population were patients under 18 years of age who were involved in motorcycle accidents treated at the Pediatric Hospital of Sinaloa in a period between January 1st, 2015 and December 31, 2017. Results: The most affected gender was the male with the most frequent age of 14 years, accidents occurred more frequently on Fridays and Saturdays at night. July was the month with the highest frequency of accidents. The number of accidents increased every year. Most of the injured were passengers, 98.4% did not use safety equipment, the most frequent injury was head injury, followed by injuries in lower extremities, upper chest trauma and less frequent abdominal traumatism. Discussion: There is a progressive increase in motorcycle accidents where the pediatric population is involved, the use of helmet is almost zero, most of the patients presented with head trauma, this study serves to see the current situation, as well as being the basis for Subsequent studies and conduct more campaigns for the prevention of motorcycle accidents and encourage the use of helmet in pediatric patients.

Traumatismo cerrado de colon con lesión sigmoidea / Blunt trauma of colon with sigmoid injury

Se trataba de una paciente de 71 años de edad y aparente buen estado de salud anterior, quien sufrió un traumatismo abdominal cerrado a causa de un accidente doméstico (caída de sus pies), que lesionó el sigmoide y trastornó el paso de asas intestinales delgadas a través de él, de modo que estas se exteriorizaron por el ano. Fue intervenida con urgencia para reintroducirle las asas por el mismo trayecto de salida y suturar la lesión colónica. La paciente evolucionó favorablemente, comprobado en varias consultas posoperatorias.

This is a 71 year-old patient with apparent previous good health state who suffered a blunt abdominal trauma due to a domestic accident (fall on her feet) which injured the sigmoid and it resulted in the passing of thin intestinal loops through it, so that these came out through the anus. She had a surgical emergency for reintroducing her loops through the same place and for suturing the colonic injury. The patient had a favorable clinical course and this was checked in several postoperative outpatient visits.

Morbilidad y mortalidad por traumatismo con lesión visceral / Morbidity and Mortality due to Trauma with visceral injury

Se efectuó un estudio descriptivo y transversal de los pacientes con traumatismos abdominales ingresados en el Hospital Provincial Docente Dr Joaquín Castillo Duany de Santiago de Cuba, desde enero del 2002 hasta diciembre del 2009, para evaluar la morbilidad y mortalidad por traumas abdominales con lesión visceral. En la serie predominaron el sexo masculino, el grupo etario de 20-29 años, los traumas abdominales abiertos y la agresión con arma blanca. El intestino delgado y el hígado fueron las vísceras más lesionadas, en tanto que para el diagnóstico resultaron ser más útiles los elementos clínicos: dolor abdominal, reacción peritoneal y taquicardia. Entre las principales complicaciones prevalecieron la infección de la herida quirúrgica y el choque hipovolémico

A descriptive and cross-sectional study including patients with abdominal traumas admitted at Dr Joaquín Castillo Duany Teaching Provincial Hospital in Santiago de Cuba from January, 2002 to December, 2009 was carried out to assess the morbidity and mortality due to abdominal traumas with visceral injuries. In the series, male sex, age group from 20-29 years, open abdominal traumas and attacks using stabs were predominant. Small intestine and liver were the most affected viscera; while clinical aspects, such as abdominal pain, peritoneal reaction and tachycardia were more useful for the diagnosis. Among the main complications, the infection of surgical wound and the hypovolemic shock were predominant

La colonoscopia: ¿es un estudio pre-operatorio indispensable para la restitución del tránsito intestinal en pacientes jóvenes: portadores de colostomía por traumatismo abdominal penetrante? / Colonoscopy: is a necessary pre-operatory study for intestinal transit restitution in young patients carrying a colostomy by penetrating abdominal trauma?

Determinar el impacto de la colonoscopia como procedimiento preoperatorio requisito para la restitución del tránsito intestinal en una población portadora de colostomía por un traumatismo abdominal penetrante. Estudio descriptivo, retrospectivo observacional, donde se evalúan informes de endoscopias digestivas inferiores realizadas por el servicio de Gastroenterología del Hospital General del Oeste "Dr. José Gregorio Hernández" de Caracas, como requisito preoperatorio para la restitución del transito intestinal en pacientes portadores de colostomía por traumatismo abdominal penetrante, en el período comprendido entre enero 2004 y diciembre 2008. De una población total de 46 pacientes, se les realizó una colonoscopia a 34 (73,91%). Los 12 restantes (26,08%), no cumplían con los criterios de inclusión. de los 34 pacientes incluidos para evaluación, 22 (64,70%), presentaron colitis y recidivas por deprivación, 7 (20,59%) con estudio normal y 4 (11,76%) presentaron alguna alteración en la endoscopia digestiva inferior. En este estudio no hay evidencia que sugiera que la realización de una colonoscopia preoperatoria en la cirugía electiva de restitución de tránsito intestinal, evite la aparición de complicaciones, ni permita el diagnóstico de patologías de relevancia en la población estudiada, no teniendo ésta la importancia que se le ha otorgado hasta la actualidad.

To determine the impact of the colonoscopy as pre-operating procedure as a requirement in the population carrying of colostomy by abdominal penetrating trauma for the restitution of the intestinal transit. Descriptive, retrospective and observational study, where the inferior digestive endoscopy made by the service of Gastroenterology in Hospital General del Oeste "Dr. José Gregorio Hernández", Caracas, was valued as pre-operating requirement in carrying patients of colostomy by abdominal penetrating trauma for the restitution of the intestinal transit, in the period between January 2004 to December 2008. In a population of 46 patients, only 34 (73.91%) were included to do the colonoscopy, the others 12 (26,08%) didn't fulfill the inclusion criteria. Of the 34 patients included, 22 (64.70%) were displayed colitis and rectitis by deprivation, 7 (20.59%) were normal study and 4 (11.76%) presented others alteration in the inferior digestive endocopy. In this study there is not evidence to suggest that the realization of preoperatory colonoscopy for surgery in the restitution of intestinal transit, avoid complications or permit diagnosis of diseases in the study population, doing less important the evidence exposed until present.

Estudo de pacientes com trauma de colon em um Hospital Municipal de Emergência / Study of pacients with colon trauma in an emercency hospital

Objetivo: verificar quais as causas mais freqüentes de trauma de cólon no HPSM-MP e os tratamentos cirúrgicos propostos para estes pacientes, servindo de base para estudos de cunho analítico sobre traumas abdominais. Método: transversal analítico de prontuários do arquivo médicodo Hospital Pronto Socorro Municipal - Mário Pinotti (HPSM-MP), dos pacientes com trauma de cólon submetidos à laparotomia exploradora, no segundo semestre de 2006. Foram verificados 444 prontuários referentes às laparotomias, dos quais 162 foram decorrentes de trauma abdominal e 21 envolveram o trauma de cólon. Resultados: o trauma de cólon foi observado com maior freqüência em indivíduos adultos jovens do sexo masculino; a principal causa foi ferimento por arma branca(52,5%); dentro da conduta cirúrgica, a sutura primária (57,1%) foi a mais adotada; o cólon transverso foi a porção mais frequentemente lesada, com 57,1% dos casos. Considerações finais: o trauma de cólon é observado com maior freqüência em indivíduos adultos jovens do sexo masculino, sendo a sua principal causa o ferimento por arma branca, uma realidade particular de Belém (PA,) e a conduta mais realizada a sutura primária.

Objective: check which causes of colon trauma occur more frequenlty and which surgical treatments are most done in these patients with colon trauma on HPSM-MP, serving as base for analytical studies about abdominal trauma. Method: transversal, cross-secondary source, with a referencepopulation of the patients who underwent in laparotomy with colon trauma on HPSM-MP in the second semester of 2006. 444 cases of laparotomy were studied, of which 162 were due to abdominal trauma and 21 involved the trauma of the colon. Results: the trauma of the colon was observed more frequently in young adult males, the main cause of firearm injury was white (52.5%) in the surgical practice, the primary suture (57.1%) was the most used and the transverse colon was the mostfrequently injured portion, with 57.1% of cases. Final considerations: the colon trauma is observed more often in young adult males, being the main cause the white weapon injury, a particularly realityin Belém (PA), and the surgical conduct most use, was primary suture.

Febre crônica associada a abscesso esplênico causado por Staphylococcus epidermidis / Chronic fever associated with splenic abscess due to Staphylococcus epidermidis

Abscessos ocultos são causa freqüente de febre crônica. Os abscessos esplênicos são entidades raras, usualmente associadas a quadros subjacentes de cirurgia abdominal, endocardite ou imunodepressão. Apresenta-se um caso de paciente com febre prolongada causada por um abscesso esplênico, cujo principal diagnóstico diferencial era leishmaniose visceral, que provavelmente esteve associado a traumatismo abdominal. O tratamento consistiu em antibioticoterapia seguida de esplenectomia.

Occult abscesses are frequent causes of chronic fever. Splenic abscesses are rare entities that are usually associated with underlying conditions such as abdominal surgery, endocarditis or immunodepression. We report on the case of a patient with prolonged fever caused by a splenic abscess, whose main differential diagnosis was visceral leishmaniasis. However, this condition was probably related to abdominal trauma. The treatment consisted of antibiotics followed by splenectomy.