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      Predictores de mortalidad tardía en niños politraumatizados Translated title: Predictors of late mortality in pediatric trauma patients

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          Abstract

          Introducción: El traumatismo constituye una de las principales causas de mortalidad y morbilidad en niños mayores de 2 años de edad. Métodos: Para identificar predictores de mortalidad tardía en niños politraumatizados entre 2 y 15 años de edad se realizó un estudio observacional, analítico y prospectivo, donde se incluyeron 82 pacientes politraumatizados, divididos según la sobrevivencia. Resultados: La mortalidad tardía fue del 20,7%. En el análisis univariable los factores asociados a mortalidad luego de 24 horas de admitido el paciente fueron: trauma craneoencefálico, lesión de víscera sólida abdominal, GCS (Glasgow Coma Score) < 9 puntos, PTS (Pediatric Trauma Score) < 4 puntos, PRISM (Pediatric Risk of Mortality score) > 20 puntos, coma prolongado, shock, coagulopatía y falla multiorgánica. Mediante regresión logística binaria se identificó como predictores independientes de mortalidad tardía en niños politraumatizados: trauma craneoencefálico (RO: 2,5; 95% IC 1,8 - 8,9, p = 0,039), lesión de víscera sólida abdominal (RO: 1,9; 95% IC 1,5 - 17,3, p = 0,047), PTS < 4 puntos (RO: 3.1; 95% IC 1,7 - 12,8, p = 0,012) y PRISM score > 20 puntos (RO: 3,3; 95% IC 2,2 - 9,2, p = 0,010). La curva ROC mostró un área bajo la curva de 0,803. Conclusión: El PTS y PRISM score son herramientas fiables para predecir mortalidad tardía en niños politraumatizados. El trauma craneoencefálico continúa siendo un predictor importante de mortalidad en el politraumatizado. Diagnosticar precozmente y optimizar el manejo de las lesiones de vísceras sólidas abdominales podría mejorar la sobrevida en este grupo de pacientes. El modelo final resulta útil para predecir desenlace fatal en niños politraumatizados.

          Translated abstract

          Introduction: Trauma is the predominant cause of morbidity and mortality among children over 2 years of age. Methods: To identify predictors for late mortality in pediatric trauma patients between 2 and 15 years of age, an observational, analytical and prospective study was conducted with 82 polytrauma patients, divided according to survival. Results: Late mortality was 20.7%. In a univariate analysis, the factors associated with mortality 24 hours after admission were: traumatic brain injury, intra-abdominal solid organ injury, GCS (Glasgow Coma Score) < 9 points, PTS (Pediatric Trauma Score) < 4 points, PRISM (Pediatric Risk of Mortality score) > 20 points, prolonged coma, shock, coagulopathy and multiple organ failure. By means of binary logistic regression, traumatic brain injury (OR: 2.5; CI 95% 1.8 - 8.9, p = 0.039), intra-abdominal solid organ injury (OR: 1.9; CI 95% 1.5 - 17.3, p = 0.047), PTS < 4 points (OR: 3.1; CI 95% 1.7 - 12.8, p = 0.012) and PRISM score > 20 points (OR: 3.3; CI 95% 2.2 - 9.2, p = 0.010) were identified as predictors of late mortality in pediatric trauma patients. ROC curve showed an area under the curve of 0.803. Conclusion: PTS and PRISM score are reliable tools to predict late mortality in children with polytrauma. Traumatic brain injury remains a significant predictor of mortality in children with multiple traumas. Early diagnosis and optimizing management of intra-abdominal solid organ injury may improve survival in this group of patients. The final model is useful for predicting fatal outcome in pediatric trauma patients.

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          Most cited references43

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          The global burden for disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020

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            Pathophysiology of polytrauma.

            Immediate and early trauma deaths are determined by primary brain injuries, or significant blood loss (haemorrhagic shock), while late mortality is caused by secondary brain injuries and host defence failure. First hits (hypoxia, hypotension, organ and soft tissue injuries, fractures), as well as second hits (e.g. ischaemia/reperfusion injuries, compartment syndromes, operative interventions, infections), induce a host defence response. This is characterized by local and systemic release of pro-inflammatory cytokines, arachidonic acid metabolites, proteins of the contact phase and coagulation systems, complement factors and acute phase proteins, as well as hormonal mediators: it is defined as systemic inflammatory response syndrome (SIRS), according to clinical parameters. However, in parallel, anti-inflammatory mediators are produced (compensatory anti-inflammatory response syndrome (CARS). An imbalance of these dual immune responses seems to be responsible for organ dysfunction and increased susceptibility to infections. Endothelial cell damage, accumulation of leukocytes, disseminated intravascular coagulation (DIC) and microcirculatory disturbances lead finally to apoptosis and necrosis of parenchymal cells, with the development of multiple organ dysfunction syndrome (MODS), or multiple organ failure (MOF). Whereas most clinical trials with anti-inflammatory, anti-coagulant, or antioxidant strategies failed, the implementation of pre- and in-hospital trauma protocols and the principle of damage control procedures have reduced post-traumatic complications. However, the development of immunomonitoring will help in the selection of patients at risk of post-traumatic complications and, thereby, the choice of the most appropriate treatment protocols for severely injured patients.
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              Internacional pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in pediatrics

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                Author and article information

                Contributors
                Role: ND
                Journal
                avpp
                Archivos Venezolanos de Puericultura y Pediatría
                Arch Venez Puer Ped
                Sociedad Venezolana de Puericultura y Pediatría (Caracas )
                0004-0649
                June 2015
                : 78
                : 2
                : 52-58
                Affiliations
                [1 ] Hospital Universitario de Pediatría Dr. Agustín Zubillaga Venezuela
                Article
                S0004-06492015000200003
                ef5204c0-5e62-4fa7-9f58-1bde10ff5b8e

                http://creativecommons.org/licenses/by/4.0/

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                SciELO Venezuela

                Self URI (journal page): http://www.scielo.org.ve/scielo.php?script=sci_serial&pid=0004-0649&lng=en
                Categories
                HEALTH CARE SCIENCES & SERVICES
                HEALTH POLICY & SERVICES
                PEDIATRICS

                Pediatrics,Health & Social care,Public health
                Trauma,Politraumatizado,Mortalidad,Predictores,Niños,Multiple injury,Mortality,Predictors,Children

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