RESUMEN

BACKGROUND: Pandemics with devastating morbidity and mortality have occurred repeatedly throughout recorded history. Each new scourge seems to surprise governments, medical experts, and the public. The SARS CoV-2 (COVID-19) pandemic, for example, arrived as an unwelcome surprise to an unprepared world. DISCUSSION: Despite humanity's extensive experience with pandemics and their associated ethical dilemmas, no consensus has emerged on preferred normative standards to deal with them. In this article, we consider the ethical dilemmas faced by physicians who work in these risk-prone situations and propose a set of ethical norms for current and future pandemics. As front-line clinicians for critically ill patients during pandemics, emergency physicians will play a substantial role in making and implementing treatment allocation decisions. CONCLUSION: Our proposed ethical norms should help future physicians make morally challenging choices during pandemics.

Asunto(s)

COVID-19 , Obligaciones Morales , Médicos , Humanos , COVID-19/epidemiología , Pandemias , Triaje

RESUMEN

Acute thoracic aortic dissection is an uncommon, although not rare, life-threatening condition. With protean signs and symptoms that often suggest more common cardiac or pulmonary conditions, it can be difficult to diagnose. Ultrasound has proven useful in making the correct diagnosis. This case demonstrates that training gained using standard ultrasound machines can be easily and successfully adapted to newer handheld ultrasound devices. The examination technique using the handheld device is illustrated with photos and a video.

Asunto(s)

Aneurisma de la Aorta Torácica/diagnóstico por imagen , Disección Aórtica/diagnóstico por imagen , Humanos , Ultrasonografía/instrumentación

RESUMEN

BACKGROUND: Inhaled ß-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. OBJECTIVE: Our aim was to evaluate ED medical personnel's baseline knowledge of MDI use and the utility of brief education on their ability to use MDIs. METHODS: After providing written consent, a spirometry nurse evaluated emergency physicians and nurses on their ability to properly perform three (open-mouth/two-finger, spacer, and closed-mouth) MDI techniques. The same spirometry nurse then gave a short educational session demonstrating the proper MDI techniques. Two weeks later, the nurse re-evaluated the same personnel on their MDI techniques. RESULTS: All emergency medical personnel initially performed poorly in demonstrating proper MDI technique, averaging 29.8% steps done correctly. Two weeks after their educational session, they improved greatly, averaging 89.4% steps done correctly. CONCLUSIONS: This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people's ability to use, and presumably to instruct patients/parents in proper use of, MDIs.

Asunto(s)

Asma , Inhaladores de Dosis Medida , Administración por Inhalación , Asma/tratamiento farmacológico , Servicio de Urgencia en Hospital , Humanos , Nebulizadores y Vaporizadores

RESUMEN

BACKGROUND: Ketamine's application in psychiatry have expanded, but it appears never to have been previously used to diagnose and treat patients with catatonia-like syndrome that occasionally present to emergency departments. CASE REPORT: A 23-year-old male was observed to suddenly stop talking. His ED GCS was 8 and had normal vital signs. While verbally unresponsive, he refused to open his eyes, demonstrated waxy flexibility of his arms, but the balance of his physical, neurological, and laboratory exams were normal. Strongly suspecting a catatonic state, they needed to rapidly confirm that diagnosis or begin evaluating him for potentially life-threatening non-psychiatric illnesses. Lacking other diagnostic modalities, they administered low-dose ketamine boluses. Ketamine 25 mg (1 mL) was diluted in 9 mL NS (2.5 mg/mL). Based on similar protocols, 1 mL of the solution (0.03 mg/Kg) was given intravenously every few minutes. After 12.5 mg ketamine, he was conscious and verbal. Subsequent history confirmed a prior episode requiring an extensive, non-productive medical evaluation. Psychiatry later confirmed the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with catatonia-like states pose a difficult diagnostic and therapeutic dilemma. Multiple interventions have been used with varying success. Optimal interventions provide a rapid resolution (or demonstrate that a psychiatric cause is not likely), be safe, encompass few contraindications, and be familiar to the clinician. In our patient, subanesthetic doses of ketamine fulfilled these criteria and successfully resolved the condition. If shown effective in other cases, ketamine would be a valuable addition to our psychiatric armamentarium.

Asunto(s)

Catatonia , Antagonistas de Aminoácidos Excitadores , Ketamina , Adulto , Catatonia/diagnóstico , Catatonia/tratamiento farmacológico , Antagonistas de Aminoácidos Excitadores/uso terapéutico , Humanos , Ketamina/uso terapéutico , Masculino , Síndrome , Adulto Joven

RESUMEN

BACKGROUND: More than 1500 scorpion species exist worldwide, with a few scorpion species potentially lethal to humans. About 1 million stings annually result in >3000 deaths, but the incidence and mortality vary greatly by species and location. Physicians working internationally must recognize that resulting toxidromes vary significantly by region. Over the past few decades, South America has reported relatively few deaths and low case mortality rates from envenomations. In Guyana, a small tropical country on its northeast coast, they have been extremely rare. A sudden fatal case cluster suggests an extension of the black scorpion's habitat, an increase in venom toxicity, or both. CASE REPORTS: During a 12-month period, Guyana experienced 3 deaths, including 1 adult, from black scorpion (Tityus obscurus) envenomation. The 30-year-old man and 2 young children experienced the same symptom complex, initially appearing well except for pain at the sting site. They soon developed persistent emesis and leukocytosis. All were flown from remote jungle areas to the only public tertiary care hospital where they received maximal available medical support. They gradually developed profound cardiopulmonary failure requiring ventilation and, eventually, dysrhythmias. None had hyperglycemia or pancreatitis, and they had no neurologic abnormalities until developing progressive obtundation immediately before intubation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Scorpion envenomation symptoms, outcomes, and treatment are geographically specific. Patients benefit when clinicians recognize the worldwide variations in grading systems and treatment options, which we discuss and compare to our patients.

Asunto(s)

Mortalidad/tendencias , Venenos de Escorpión/efectos adversos , Escorpiones , Adulto , Animales , Preescolar , Guyana/epidemiología , Humanos , Masculino , Venenos de Escorpión/sangre

RESUMEN

INTRODUCTION: Although the fascia iliaca compartment block (FICB) seems to be an ideal technique for femoral neck and shaft fractures occurring in resource-poor settings, it has been unclear how effective it is when used by emergency physicians (EP) with little training in the technique, using equipment, medications and methods that differ from those commonly available in developed countries. This series was designed to demonstrate that EPs in a resource-poor setting can provide effective analgesia for femur fractures with anatomic landmark-guided FICBs, clinician-compounded lidocaine-epinephrine (1:100,000), and a standard injection needle. METHODS: Over a three-month period, patients ≥12 years old presenting to the emergency department with hip or femur fractures and a Likert visual analogue scale >4 had an EP-administered FICB. EPs used a standard intramuscular needle and a lidocaine-epinephrine solution they compounded at the bedside and located the injection site using only anatomic landmarks. EPs evaluated the patient's pain level at 30 minutes and at two hours post-FICB. We also reviewed articles since 2016 that describe the FICB. RESULTS: We enrolled a non-consecutive sample of 10 patients in the case series. Five had femoral neck (hip) fractures and five had femoral shaft fractures. All patients had a reduction in their pain levels after the FICB. On average, the block took effect about three minutes after injection. At 30 minutes all patients reported clinically meaningful pain reduction. The analgesic effect of the compounded agent lasted approximately 200 minutes. No adverse effects were reported. No published journal articles about FICB since 2016 were from resource-poor settings, and only one was from a developing country. CONCLUSION: This series suggests that the FICB is effective even when performed with the minimal materials that are usually available in resource-poor settings. Methods such as this, which use simplified clinical tests and techniques applicable in resource-poor settings, can assist global emergency medicine (EM). We can assist global EM by similarly finding methods to simplify useful clinical tests and techniques that can be used in resource-poor settings.

RESUMEN

Discussions of consent for research in Emergency Medicine and for procedures during medical emergencies must take into account the nature of both the specialty and the patients that present to emergency departments. With this knowledge, it becomes clear that, popular misconceptions to the contrary, Emergency Medicine research plays a vital role in care, and informed consent (or waiver for minimal-risk research) remains the standard for most emergency care research. Indeed, to publish research in peer-reviewed journals requires evidence of a research ethics committee's approval, which usually means obtaining informed consent but can also include (in the United States) a waiver or intense review and ongoing oversight. Such review and oversight, termed Retrospective/Deferred Consent, is a way of permitting research without prospective informed consent in the very limited circumstances of life- or limb-threatening diseases or injuries. Research Ethics Committees only approve Retrospective/Deferred Consent when no other option exists, when clinical equipoise exists, and when they can carefully monitor the study. Research performed in such time-sensitive clinical situations, once banned as unethical, has led to vital lifesaving alterations in medical practice affecting millions of patients.

Asunto(s)

Investigación Biomédica , Servicios Médicos de Urgencia , Consentimiento Informado , Humanos

RESUMEN

Jaguar attacks on humans rarely occur in the wild. When they do, they are often fatal. We describe a jaguar attack on a three-year-old girl near her home deep in a remote area of the Guyanese jungle. The patient had a complex but, relatively, rapid transport to a medical treatment facility for her life-threatening injuries. The child, who suffered typical jaguar-inflicted injury patterns and survived, is highlighted. We review jaguar anatomy, environmental status, hunting and killing behaviors, and discuss optimal medical management, given the resource-limited treatment environment of this international emergency medicine case.

Asunto(s)

Mordeduras y Picaduras/cirugía , Panthera , Animales , Mordeduras y Picaduras/etiología , Preescolar , Tratamiento de Urgencia , Femenino , Humanos

RESUMEN

INTRODUCTION: This study aimed to determine the dislocation and reoperation rate, functional outcomes, and the survival rate of the unique subset of very old but lucid and independent patients with hip fractures following a total hip arthroplasty (THA) and geriatric team-coordinated perioperative care. METHOD: Between 2000 and 2006, previously independent ambulatory patients ≥80 years old presenting with an intracapsular hip fracture were given THAs under the care of an integrated orthopedic surgery-geriatric service. Their fracture-related complications, ambulation, mental status, and survival were followed for 5 to 11 years postinjury. RESULTS: Five years postinjury, 57 (61.3%) patients of the original study group were living. In all, 3 (3.2%) patients had postoperative hip dislocations (and 2 patients had dislocation twice) and 2 reoperations were needed within the first postoperative month. There were no hip dislocations or reoperations after the first year. Radiographs obtained on 88% of the surviving patients at 5 years postoperatively showed that all remained unchanged from their immediate postoperative images. Nearly half of the patients were still able to ambulate as they did preoperatively and their mixed-model equation was statistically unchanged. CONCLUSION: This study of patients >80 years old with previously good functional status demonstrates that with appropriate surgical (best prosthesis, good operating technique, and regional anesthesia) and geriatric (pre- and postoperative assessments, close follow-up, medication adjustments, and fall-prevention instruction) care, they have few hip dislocations and reoperations, survive postfracture at least as long as their noninjured contemporaries, and continue to function and ambulate as they did prior to their injury.

RESUMEN

BACKGROUND: Thromboprophylaxis for deep vein thrombosis (DVT) after lower-extremity trauma could include rivaroxaban, an oral medication that does not need laboratory monitoring. OBJECTIVE: To assess rivaroxaban's efficacy in preventing DVTs after pelvic trauma compared to its historical incidence. MATERIALS AND METHODS: All patients admitted with pelvic fractures in a 12-month period followed a standardized thromboprophylaxis protocol: 1) rivaroxaban 10 mg/day within 24 h of injury or upon hemodynamic stability; 2) pre-operative, post-operative, and 30-day extremity ultrasound; 3) ventilation-perfusion scintigraphy for clinical signs of pulmonary embolus; and 4) a 45-, 90-, and 120-day re-evaluation. Rivaroxaban administration ceased the day of surgery and restarted 12 h post-operatively or upon hemodynamic stability, continuing for 30 days. Excluded patients had severe neurological or hepatosplenic injuries, heparin hypersensitivity, or hemodynamic instability. RESULTS: Of 113 patients assessed, 84 patients (66 males), average age 46.6 years (range 19-69 years), were included. They had isolated pelvic trauma (n = 37), associated lower limb injuries (n = 47), average Injury Severity Score 21.4 (range 16-50), and average Glasgow Coma Scale score 13.6 (range 9-15). Patients receiving thromboprophylaxis soon after their fracture (n = 64) had a lower incidence of DVT than those receiving delayed thromboprophylaxis (n = 20) (p = 0.02). One patient (1.2%) died from a pulmonary embolus; 13 had asymptomatic below-the-knee DVTs. Rivaroxaban did not increase intra- or post-operative bleeding in surgical wounds. CONCLUSIONS: DVT incidence after pelvic fractures is reduced by administering antithrombotics within 24 h of injury or, if the patient is hemodynamically unstable, 24 h after stabilization. Rivaroxaban is a safe and effective method of providing this thromboprophylaxis.

Asunto(s)

Anticoagulantes/administración & dosificación , Fracturas Óseas/complicaciones , Morfolinas/administración & dosificación , Huesos Pélvicos/lesiones , Tiofenos/administración & dosificación , Trombosis de la Vena/prevención & control , Adulto , Anciano , Anticoagulantes/uso terapéutico , Esquema de Medicación , Femenino , Fracturas Óseas/cirugía , Escala de Coma de Glasgow , Humanos , Puntaje de Gravedad del Traumatismo , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/diagnóstico por imagen , Extremidad Inferior/lesiones , Masculino , Persona de Mediana Edad , Morfolinas/uso terapéutico , Embolia Pulmonar/diagnóstico por imagen , Cintigrafía , Rivaroxabán , Tiofenos/uso terapéutico , Factores de Tiempo , Ultrasonografía , Trombosis de la Vena/diagnóstico , Trombosis de la Vena/etiología , Adulto Joven

RESUMEN

BACKGROUND: Improved diagnostic tests would aid in diagnosing and treating community-acquired meningitis. OBJECTIVE: To analyze the diagnostic value of interleukin-6 (IL-6) in the cerebrospinal fluid (CSF) of patients presenting with symptoms of acute meningitis. MATERIAL AND METHODS: In a 6-month prospective, observational, cross-sectional emergency department (ED) study, serum and CSF samples were obtained from all patients with a headache and fever in whom the physician suspected meningitis. Patients were excluded if computed tomography findings contraindicated a lumbar puncture, if they had bleeding disorders, or if their serum indicated bleeding. IL-6 levels were measured and compared in patients with (Group A) and without (Group B) bacterial meningitis. RESULTS: Samples were obtained from 53 patients, of whom 40 were ultimately found to have meningitis. These 40 patients averaged 49.6 ± 21.9 years, with number of men 18 (45%), hospitalizations 21 (52%), mortality 3 (.07%), and IL-6 average rating 491 (median: 14.5; range 0000-6000). Findings in the two groups were: Group A (with meningitis): n = 13, average IL-6 level: 1495 (median: 604; 25/75 percentiles: 232.5-2030; 95% confidence interval [CI] 371.7-2618.6; range 64-6000). Group B (with aseptic meningitis): n = 27, average IL-6 level: 7.34 (median: 5; 25/75 percentiles: 0.0/15.1; 95% CI 3.94-10.73; range 0-23.6). Mann-Whitney rank sum test: p < 0.0001. CONCLUSIONS: In patients with acute bacterial meningitis, CSF cytokine concentrations are elevated. Measuring CSF inflammatory cytokine levels in patients with acute meningitis could be a valuable ED diagnostic tool. Using this tool could improve the prognosis of patients with bacterial meningitis by allowing more rapid initiation of antibiotic treatment.

Asunto(s)

Interleucina-6/líquido cefalorraquídeo , Meningitis Aséptica/líquido cefalorraquídeo , Meningitis Aséptica/diagnóstico , Meningitis Bacterianas/líquido cefalorraquídeo , Meningitis Bacterianas/diagnóstico , Enfermedad Aguda , Adolescente , Adulto , Anciano , Estudios Transversales , Servicio de Urgencia en Hospital , Femenino , Fiebre/etiología , Cefalea/etiología , Hospitalización , Humanos , Masculino , Meningitis por Haemophilus/líquido cefalorraquídeo , Meningitis por Haemophilus/diagnóstico , Meningitis por Listeria/líquido cefalorraquídeo , Meningitis por Listeria/diagnóstico , Meningitis Meningocócica/líquido cefalorraquídeo , Meningitis Meningocócica/diagnóstico , Meningitis Neumocócica/líquido cefalorraquídeo , Meningitis Neumocócica/diagnóstico , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Estudios Prospectivos , Estadísticas no Paramétricas , Adulto Joven

RESUMEN

As emergency medicine (EM) has developed as a medical specialty throughout the world, each country has followed its own path to official recognition. Despite a successful EM model in the United States, some countries, especially those that require government approval of new medical specialties, have often found it difficult to attain recognition. As of early 2009, Argentina had yet to recognize EM as an official specialty, although some regional governments have acknowledged the specialty's status. The Argentine Society of EM has taken a number of steps and proposed educational paths to EM specialization to convince Argentina's political decision-makers that Emergency Medicine is a fundamental step toward a modern medical system. Such national recognition would further an already thriving EM community and improve the quality of patient care in Argentina. To assist colleagues around the world who are pursuing or will pursue this goal, this article outlines Argentina's complex and ongoing path to specialty recognition.

Asunto(s)

Medicina de Emergencia/educación , Medicina de Emergencia/legislación & jurisprudencia , Internado y Residencia , Concesión de Licencias , Argentina , Certificación , Curriculum , Medicina de Emergencia/normas , Humanos , Internet

RESUMEN

BACKGROUND: Impaired consciousness without a history of trauma is a common reason for emergency department (ED) visits. Among critically ill patients with a history and physical findings suggestive of a cerebrovascular accident (CVA), it may be difficult to differentiate between a structural and a non-structural cause for their condition. OBJECTIVES: This study was conducted to determine if lactic dehydrogenase (LDH) levels in the cerebrospinal fluid (CSF) of patients with acute non-traumatic neurological disorders could distinguish between structural and non-structural etiologies. MATERIAL AND METHODS: Over a 6-month period, CSF specimens were collected from 54 critically ill patients admitted to the ED with impaired consciousness and findings consistent with a CVA. The patients had moderate to severe impairment of consciousness, had a new motor or sensory deficit, or had meningeal signs of recent onset. CSF-LDH levels were analyzed because CSF levels of the enzyme are typically elevated in meningitis, metastatic cancer, and disorders resulting in ischemic necroses. Patients were excluded if a computed tomography scan showed contraindications to performing a lumbar puncture, if they had a coagulopathy, or if the CSF was xanthochromic or produced visible blood sediment after centrifuging. The data were analyzed according to the patients' admission diagnoses-structural vs. non-structural lesion. RESULTS: Of the samples collected from 54 patients, eight were excluded. Among the 46 patients included in the study, the mean age was 56.1 +/- 2.75 years, mean APACHE II score was 20.93 +/- 0.98, Glasgow Coma Scale (GCS) score was 7.15 +/- 0.49, and mortality was 55% (22 patients). The 30 patients with a structural abnormality had a mean age of 56.7 +/- 3.55 years, GCS score of 7.3 +/- 0.61, APACHE II score of 20.2 +/- 1.1, mortality of 43% (13 patients), and CSF-LDH level of 128.8 +/- 24.8 IU/L (95% confidence interval [CI] 78.1-179.6). The 16 patients with a non-structural (metabolic) disturbance had: a mean age of 55.0 +/- 4.42 years, GCS score of 6.87 +/- 0.86, APACHE II score of 22.2 +/- 1.94, mortality of 56% (9 patients), and CSF-LDH level of 29.8 +/- 2.9 IU/L (95% CI 23.6-36.1). Analysis by Student's t-test was p < 0.05. When the diagnostic value of CSF-LDH level was evaluated using a cutoff point of 40 IU/L, the following results were obtained: sensitivity: 86.7%, specificity: 81.3%, pretest likelihood: 65%, positive predictive value: 90%, negative predictive value: 76%, Likelihood Ratio (LR)+: 4.62, LR-: 0.16 (6.25-fold increase). CONCLUSIONS: In critically ill patients with acutely altered levels of consciousness but without a history of trauma, a CSF-LDH value < or = 40 IU/L is associated with non-structural pathology.

Asunto(s)

Trastornos de la Conciencia/enzimología , L-Lactato Deshidrogenasa/líquido cefalorraquídeo , Accidente Cerebrovascular/enzimología , APACHE , Biomarcadores/líquido cefalorraquídeo , Enfermedad Crítica , Estudios Transversales , Servicio de Urgencia en Hospital , Femenino , Escala de Coma de Glasgow , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Prospectivos

RESUMEN

Hip fractures can cause considerable pain when untreated or under-treated. To enhance pain relief and diminish the risk of delirium from typically administered parenteral analgesics and continued pain, we tested the efficacy of using fascia-iliaca blocks (FICB), administered by one of four attending physicians working in the emergency department (ED), with commonly available ED equipment. After informed consent, a physician administered one FICB to 63 sequential adult ED patients (43 women, 20 men; ages 37-96 years, mean 73.5 years) with radiographically diagnosed hip fractures. Under aseptic conditions, a 21 g, 2-inch IM injection needle was inserted perpendicularly to the skin 1 cm below the juncture of the lateral and medial two-thirds of a line that joins the pubic tubercle to the anterior superior iliac spine. The needle was inserted until a loss of resistance was felt twice (fascia lata and fascia iliaca), at which point 0.3 mL/kg of 0.25 bupivacaine was infused. The physician tested the block's efficacy by assessing sensory loss. Pain assessments were done using a 10-point Likert Visual Analog Scale (VAS) before, and at 15 min, 2 h, and 8 h post-block. Block failure was having the same level of pain as before the block. Oral analgesics were administered as needed. The IRB approved this study. Post-procedure pain was reduced in all patients, but not completely abolished in any. Before the FICB, the pain ranged from 2 to 10 points (average 8.5) using the VAS; at 15 min post-injection, it ranged from 1 to 7 points (average 2.9); at 2 h post-injection, it ranged from 2 to 6 points (average 2.3); at 8 h post-injection, it ranged from 4 to 7 points (average 4.4). Analgesic requests in the first 24 h after admission averaged 1.2 doses (range 1 to 4 doses) of diclofenac 75 mg. There were no systemic complications and only two local hematomas. Resident physicians learned the procedure and could perform it successfully with less than 5 min instruction. Physicians rarely use the FICB in EDs, although the technique is simple to learn and use. This rapid, effective, and safe method of achieving excellent pain control in ED patients with hip fractures can be performed using standard ED equipment.

Asunto(s)

Fracturas de Cadera/complicaciones , Bloqueo Nervioso/métodos , Manejo del Dolor , Adulto , Anciano , Anciano de 80 o más Años , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Servicio de Urgencia en Hospital , Fascia/inervación , Estudios de Factibilidad , Femenino , Humanos , Ilion/inervación , Masculino , Persona de Mediana Edad , Dolor/etiología , Dimensión del Dolor , Estudios Prospectivos , Resultado del Tratamiento

RESUMEN

In the past decade, México, with the third largest population of any country in the Americas, has experienced rapid growth in Emergency Medicine education. Emergency Medicine residency programs began in México City in 1986 and in 1991, spread throughout the country when the Medical Institute of Social Services (IMSS) instituted programs at their specialty hospitals. Although pre-hospital care is still rudimentary in many parts of the country and there are insufficient numbers of trained emergency physicians to staff the nation's Emergency Departments, the growth of the specialty is helping to improve the quality of medical care in México. This article discusses the current condition of and prospects for Emergency Medicine in México within the context of its medical system, and outlines objectives and guidelines for future developments.

Asunto(s)

Medicina de Emergencia/estadística & datos numéricos , Internado y Residencia , Adulto , Servicios Médicos de Urgencia/organización & administración , Medicina de Emergencia/educación , Medicina de Emergencia/tendencias , Humanos , México

RESUMEN

As neonatology continues to advance medical knowledge and situations surrounding the care of ill and premature newborns, each step introduces ill- defined methodologies, unknown outcomes, and increasing costs. In countries such as Mexico, the government hospitals assume the cost of such treatments. It is, therefore, incumbent on the entire society, rather than simply the medical community, to enter into the debate about which of these tiny patients should be treated, how aggressive such treatment should be, and what outcomes are acceptable.We suggest an appropriate strategy for countries like Mexico, with an intermediate policy between treating all the very low birth weight babies (VLBW) and offering strict limits, where all the parts are involved in the decision making process.

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La neonatología continúa avanzando en el conocimiento médico y en las condiciones que rodean el cuidado de neonatos enfermos y prematuros. Cada paso introduce metodologías definidas para cada enfermedad, resultados inciertos, y costos crecientes. En países como México, generalmente estos niños son atendidos al través de los hospitales públicos; por tanto, el Estado asume el costo. Es, por consiguiente, responsabilidad de la sociedad entera, y no solo simplemente de la comunidad médica, discutir sobre qué se debe hacer en pacientes diminutos, hasta dónde realizar tratamientos agresivos, y qué resultados son aceptables. Se propone una estrategia adecuada a la situación de México, intermedia entre tratar a todos los prematuros de muy bajo peso u ofrecer límites estrictos, donde se involucren todas las partes en la toma de decisiones.