[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.

[Spinal cord and vertebral column injuries in children]. / Lesiones raquimedulares en la infancia.

AIMS: Analysis of main factors of spinal cord and vertebral column injuries in our environment. METHODS: We reviewed the data collected from the patients (n = 2640) admitted to our hospital because of trauma and included in our Registry from January 1995 to April 2002. Among this group, 86 patients (3.3%) had spinal cord and vertebral column injuries and were included in the study. RESULTS: Group gender distribution was 45 males and 41 females. In our group, 71 patients suffered vertebral fractures, 3 of them with spinal cord injuries (4.2%), 13 patients with vertebral subluxation, 11 of them between C1-C2, and 2 patients with spinal cord injury without radiographic abnormality. Only 71 patients, 4.9% of the total of the patients who were admitted with any type of fracture (n=1457), suffered vertebral fractures. These patients suffered 130 vertebral fractures, 35 of them (49.3%) suffered multiple fractures. Thoracic vertebrae were the most frequently affected (n=82, 63%). The most frequent localization was T4 toT8 (n=50, 38.5% and T11 to L2 (n=41, 31.5%). Age ranged between 12 and 15 years (n=35, 49.3%), with only 5 patients under 6 years. 90.9% of the patients with lumbar fractures were older than 8 years and 76.9% of the patients with cervical fractures were over 8 years. Motor vehicle accident was the most common cause in our series (n=20, 23.3%). 81% of these patients did not use safety belt. Ten children with cervical injuries were seen by medical staff at the prehospital stage, and only 4 of them arrived to Hospital with cervical collar. There were thirty five patients with thoracic or lumbar injuries but only 27 of them were transferred to our Institution by ambulance. Surgery was required in 2 patients, both of them with unstable fractures. Mean hospital stay was 17,1 days (range 2-37 days). CONCLUSIONS: Group gender distribution is similar between males and females and the incidence in our series is higher than other series of the literature. Thoracic injuries are the most frequent. It is necessary to improve prehospital management of these patients and to increase the use of safety belt. Spine injury incidence increased with age.

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.

[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.

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.

[Thyroid tumors in childhood]. / Tumores tiroideos en la infancia.

The thyroid pathology in the paediatric population represents 5% of the total and 1.2% only thyroid pathology correspond to the infantile solitary thyroid nodules. Most of them are asymptomatic and as only sign an increase of volume is observed in the neck. Always we have to ask about the family history because the possibility of medullary carcinoma related with multiple endocrine neoplasias should be investigated (a patient of our series). The thyroid tumor represents 0.5% of all the tumors and of these 10% is in younger than 21 years old. We present 13 patients with thyroid pathology that have required surgical treatment, since 1983 to 1997. Five papillary carcinomas (ages: 7 to 14 years old) that started with a cervical nodule, normal thyroid function and a case of medullary carcinoma, in a multiple endocrine neoplasia (MEN II 2A). In the 5 cases of carcinoma papillary we were carried out total thyroidectomy and later on, postoperative ablative dose of 131I was administered. In the case of the girl with medullary carcinoma was carried out a total tumorectomy and lymph node excision. Finally, seven patients with nodule thyroid were thyroid benign tumors (benign 6 adenomas and 1 cyst colloid, ages: 8 to 15 years old). In all of them we were carried out total surgical excision of the thyroid nodules. Our protocol of study of nodule thyroid includes: 1) thyroid gammagraphy to know the intensity of reception of the isotope; 2) cervical ultrasound; and 3) biopsy or cytopathology of fine needle aspiration of the thyroid gland in children that it dissuades to base the surgical strategy on this test.

[Sigmoid neovagina: apropos of 2 cases]. / Neovagina con sigma: a propósito de dos casos.

The presence of ambiguous external genitals can be related with a number of nosologic entities. We can find the female form with hypertrophic clitoris and vaginal hypoplasia in a wide variety of phenotype presentations. We have two young girls with ambiguous external genitals, where we notice hypertrophic clitoris and vaginal hypoplasia, with the diagnosis of mixed gonadal dysgenesis and androgen insensitivity syndrome (Morri's Syndrome). They have been operated several times: gonadectomy, genitoplasty, vaginoplasty and mammoplasty. We have made a neovagina, using a segment of sigma and preserving the walls of the former vagina. The surgical technique we used, consisted in the abdominoperineal descent of the segment of sigmoid colon and anastomosis with the back wall of the former vagina and the perineum; after that, we split the intervaginal septum, linking these two structures and reaching a lonely introitus vaginae. The hormonal treatment for the girl with mixed gonadal dysgenesis with estrogen and progestogen induces normal menstruations; we only use estrogen for the patient with Morri's Syndrome. The histology showed that there were dysgenetic gonads in one of the patients and testicular tissue without gonadal elements. Both girls have had a good evolution, with no problems and an excellent aesthetic and functional result.

[Indications from the laparoscopic approach in pediatric urological surgery: our experience in 49 patients]. / Indicaciones del abordaje laparoscópico en cirugía urológica pediátrica: nuestra experiencia en 49 pacientes.

OBJECTIVES: To analyse the diagnostic and therapeutic potential of video-assisted laparoscopy in the urology paediatric pathology. We had analysed its indications and results, to measure in disminution of morbidity and hospital stay. PATIENTS AND METHODS: We are treated in our section of Paediatric Urology 49 patients during the period of June 1995 and December 1998, performing 51 laparoscopics procedures. The mean age was 8 years (2-16 years ago). The laparoscopic indications were diagnostic in 33 patients: intra-abdominal testes (n = 16), renal biopsy (n = 17), and terapeuthics in 16 patients (17 laparoscopics procedures): varicoceltomy (n = 7), orchiectomy (n = 1), closure peritoneal-vaginal duct (n = 2), retroperitoneal nephrectomy (n = 6), marsupilazation and omentoplastic in giant lymphocel renal post-transplantation (n = 2). RESULTS: The laparoscopic approach were effective in 100% of diagnostic procedures and 93.4% of therapeuticm procedures. Conversion in 2 cases were necessary to make renal biopsy (n = 1). We hadn't have postoperatives complications and the indices of intraoperative morbidity was of 2.4%. The mean hospital stay was 1.4 days. CONCLUSIONS: We believe that exist indications clinically stabilised of laparoscopic approach--diagnostic and therapeutic--in paediatric urology. There are others indications that its are consider anecdotal in the present but in immediately future these indications will be valid.

[Second tumors in childhood]. / Segundos tumores en la infancia.

More aggressiveness in treatment of childhood malignancies has had an evident impact on survival and rate of cure but, it has also allowed us to discover long-term effects of these treatments, and second malignant tumors of them. Between 1970 and 1993, 472 cases of malignant tumors in childhood were diagnosed in our department. Six of them (1.27%) developed a second tumor (five malignant and one benign). Relationship between first and second tumors are: seven years old boy, cervical lymphosarcoma-thyroid carcinoma; eleven years old boy, osteogenic sarcoma-vesical carcinoma: two years and six months old boy, cerebellar astrocytoma-soft tissue osteogenic sarcoma; five years old girl. Wilm's tumor-scapular osteogenic chondroma; one year and a half old girl, abdominal neuroblastoma-granulocytic sarcoma (chloroma); twelve years old boy. Hodgkin's disease-acute myeloblastic leukemia. All of them were clearly related to concogenic effect of radiation or chemotherapy.