[Acute asthmatic crisis in children]. / La crise d'asthme aigu grave de l'enfant.

Acute asthma attack in children is an attack responsible for life-threatening acute respiratory distress with partial or no response to bronchodilator drugs. The severity of the episode needs to be quickly evaluated. This presupposes a perfect knowledge of the clinical signs of severity. Treatment is urgent and first based on the administration of high doses of inhaled short-acting beta 2-agonists. In the more obstructed children, anti-cholinergic drugs can be added to nebulized beta 2-agonists. Because of their delayed effect, systemic steroids require an early prescription. Symptomatic treatments are: urgent hospitalization, oxygen if needed, proper hydratation. Continuous nebulization or intravenous perfusion of beta 2-agonists are prescribed with cardiac monitoring when no objective improvement is noted. Admission into the pediatric intensive care unit when bronchial obstruction continues will permit the association of bronchodilator drugs and the proposal of mechanical ventilation if needed. When the episode is resolved, a prophylactic treatment using inhaled corticosteroids must be prescribed. Clinical and spirometric follow-up has to be organized, and the patient and his/her family have to be educated.

[Severe trauma in children]. / Les traumatismes sévères de l'enfant.

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 developed 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 resuscitation. 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 abnormality (SC/WORA) 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.