CATATRAUMA IN CHILDREN. INTEGRATIVE APPROACH TO TREATMENT

CATATRAUMA IN CHILDREN. INTEGRATIVE APPROACH TO TREATMENT

Sinitsa N.S., Kravtsov S.A., Meshcheryakov S.A.

Regional Clinical Center of Miners’ Health Protection, Leninsk-Kuznetsky, Russia

Currently, the rate of injuries presents one of the main causes of mortality in the population. Moreover, a trend to its decreasing is not observed. Severe associated injury takes the first place among causes of mortality [1, 2]. The proportion of catatrauma takes 10-20 % among all injuries and the second place in mortality after injuries (up to 40 %) conceding to mortality after road traffic accidents (up to 75 %) [3, 4]. According to WHO, about 47 thousand of children and adolescents younger 20 die after catatrauma in the world [3].
The term catatrauma accents the mechanism of an injury. The falling causes rapid acceleration and deceleration of the body. Depending on height, contact with rigid surface usually causes a range of severe associated injuries. The emphasis on such mechanism of an injury supposes the whole range of common injuries (shock, acute massive blood loss, intracranial injuries, spine and spinal cord injuries, thoracic and abdominal injuries, fractures of extremities and pelvis etc.), resulting in need for realization of urgent medical procedures for salvation of the patient’s life. The treatment of such patients is characterized by strict subsequence, multiple stages and individuality. The optimal treatment for this category of patients is the multi-profile specialized hospital – level 1 trauma center – where the multidisciplinary approach is realized (with participation of traumatologists, intensivists, surgeons, neurosurgeons, cardiologists, pulmonologists, endoscopists, physicians of diagnostic units etc.) with use of the modern algorithms for arrangement of specialized medical care.
Annually, our center admits 10-14 patients with severe associated injuries after falling from height.
Central nervous system injuries (traumatic brain and spinal injuries) were registered in 38 % of cases.
Among thoracic injuries (74 % of cases according to our data), the common feature of catatrauma is disarrangement of supporting structure of the chest – costal and sternal fractures with contusions, lung injuries, hemopneumothorax and possible cardiac contusion. Moreover, it is often is accompanied by aspiration syndrome with subsequent development of aspiration pneumonia.
Abdominal injuries are often accompanied by hepatic and splenic injuries with acute massive blood loss. Owing to impossibility of efficient hemostasis, splenectomy was conducted for children with splenic lacerations in the place of hilus.
Skeletal injury was registered in 100 % of cases. The highest severity of condition was in common pelvic fractures of B type (AO classification) with rotation instability with preservation of vertical and transverse stability.
Objective – to show the possibilities of the integrative approach to diagnosis and treatment of a child with catatrauma.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013 and the Rules for Clinical Practice in the Russian Federation (the Order by Russian Health Ministry, 19 June 2003, No.266) with written consent for participation and use of data, and with approval from the local ethical committee of Regional Clinical Center of Miners’ Health Protection (the protocol No.23, 4 September 2018).

CLINICAL CASE

A child, age of 8, female, fell from the window of the sixth floor. The emergency care team transported her to the intensive care unit of our center 35 minutes after the injury with diagnosis: “Polytrauma”.
The prehospital stage included the examination, initiation of intensive care, immobilization, transfer (15 minutes). The volume of prehospital care: peripheral vein catheterization, infusion therapy (0.9 % natrium chloride, 150 ml), analgesia (1 % morphine, 1 ml). The cervical spine was immobilized with Philadelphia collar. The patient was put onto the handbarrow.
The multidisciplinary team (headed by the leading specialist) has been developed for arrangement of medical care for patients with polytrauma in the center. The responsible surgeon takes the role of the leading specialist in coordination and determination of subsequence of medicodiagnostic procedures. The team includes anesthesiologist-intensivist, pediatric surgeon, surgeon, neurosurgeon, traumatologist. If necessary, the following specialists are involved: cardiologist, endoscopist, physician of functional diagnostics.
The primary examination in the admission unit includes the complex of procedures for estimation of condition severity and identification of dominating components of injury and subsequence of medical procedures. The primary medical procedures in the intensive care unit are conducted according to ATLS (Advanced Trauma Life Support). Tracheal intubation, ALV, the second vascular approach, urinary bladder catheterization, gastric probe and intensive infusion-transfusion therapy were conducted.
The examination in the anti-shock room: the evolution of the child corresponded to her age. The body composition was correct. Nutrition was normal. Skin surfaces were pale. The hands and the feet were cold and dry. Visible mucosa was pale-pink and clean. Blood-colored mucosa was in the nasal cavity.
Consciousness was altered, with sopor, non-contactable. There was an extensive suffusion in the frontal region parasagitally. There were scratches on the head and the face, mainly to the right. There was a dense and soft subgaleal hematoma in the frontal sagittal region to the right. She responded to pain stimuli and opened her eyes. To the right – active differentiated responses, to the left – low differentiation. The pupils were of middle size, S = D, consensual reaction was weak. Oculocephalic reflexes were positive. Tendon reflexes were preserved, to the left – stronger.
The cervical, thoracic and lumbar parts of the spine were without changes.
The chest showed usual configuration, with uniform participation in the respiratory act. RR = 30-34. Air, SpO2 = 88-90 %. Breathing was harsh in the lungs, moderately weak in inferior lateral parts, with single rales after cough, more – to the right.
Considering the low level of consciousness and acute respiratory failure, tracheal intubation was conducted. The child was switched to artificial lung ventilation.
Cardiac tones were clear and rhythmical. Arterial pressure = 90/60 mm Hg, HR = 120 b/m, ECG (monitor) – sinus tachycardia.
The abdomen was normal, symmetrical, soft during palpation and diffusely painful. The percussion data supposed tympanitis in mesogastrium. Peristaltics was weak and auscultated. Blumberg's sign was doubtful. Kidneys, the liver and the spleen were not palpable. More detailed examination was impossible because of low level of consciousness. Considering the injury mechanism and the clinical course, a closed abdominal injury was possible and diagnostic laparoscopy was conducted.
The urinary catheter was installed. Residual urine was removed.
At admission, the blood and urine were taken for total analysis, the blood for acid-base balance analysis. Blood type and Rh-factor were determined. The primary results: Hb = 105 g/l, erythrocytes – 3.83, Ht = 30.1 %, Ph = 7.133.
The primary medical procedures with ATLS protocol were conducted in the resuscitation room. Trachea was intubated. ALV was initiated. The second vascular approach was made. The urinary bladder was catheterized. The gastric probe was installed. Intensive infusion-transfusion therapy was continued.
Instrumental diagnostics was continued, considering the stable state of the child.
Chest X-ray examination showed right-sided pneumothorax along the costal arc, with slight displacement of the mediastinum leftwards. There was a contusion of pulmonary parenchyma in inferior posterior parts.
Cerebral CT: subarachnoid bleeding in the frontotemporal occipital lobe to the right. Edema in the right hemisphere with dislocation of middle structures 3 mm leftwards. Anterior horns of 3rd ventricle were compressed because of edema. Subgaleal hematoma in the frontal region to the right.
Chest CT: minimal pneumothorax to the right, local pneumothorax to the left in the region of anterior cardiodiaphragmatic sinus. Lung contusion to the right and to the left in inferior parts of posterior segments, to the left – stronger. A small bulla in the inferior lobe to the right. A fracture of the first rib without displacement.
Cervical spine CT: no bony traumatic changes.
X-ray examination of knee joints: no bony traumatic pathology.
Lumbar spine X-ray examination: no bony traumatic pathology.
Pelvic X-ray examination: a fracture of acetabular bottom with 5 mm displacement into pelvic cavity.
X-ray examination of left ulnar joint: transcondylar extensive fracture of the humerus with displaced fragments, a fracture of the ulnar process (Fig. 1).

Figure 1. The patient Z., female, age of 8. Chest X-ray study, cerebral CT, X-ray study of broken bones at admission.

The total time of examination in the anti-shock room and primary medical procedures were 37 minutes.
The patient was transferred to the surgery room for urgent surgical interventions. The following procedures were carried out with intubation narcosis: diagnostic laparoscopy (blood in abdominal cavity); laparotomy (splenic laceration was found in the region of hilus); splenectomy, abdominal cavity draining; Bulau pleural cavity draining to the right in the 2nd intercostal space (exhaust of air and hemorrhagic discharge – about 50 ml); closed reposition of the left humerus.
Surgery time was 1 hour and 20 minutes, total external blood loss – 200 ml. Surgical treatment of pelvic fractures was not required.
After surgical treatment, the child was transferred to the intensive care unit, where intensive therapy, clinicobiological and physiological monitoring were continued.
Diagnosis after examination and surgical treatment:
“Polytrauma. Closed traumatic brain injury. Severe brain concussion. Subarachnoidal hemorrhage to the right. Subgaleal hematoma in the frontal region. Closed injury to abdominal organs. Splenic laceration. Intraabdominal bleeding. Condition after laparoscopy, laparotomy and splenectomy. Closed chest injury. A fracture of the 1st rib to the right without displacement. Contusion of inferior lobes of both lungs, injury to the right lung, closed pneumothorax to the right. Condition after draining of right pleural cavity. Multiple closed skeletal injury. A closed fracture of the pubic bone and acetabular bottom to the left with displacement. A closed bending transcondylar fracture of the left humerus with displaced fragments. A closed fracture of ulnar process of the left forearm. Traumatic shock of degree 2”.
ISS – 54 (severe brain concussion – 16, splenic rupture – 16, lung contusion, closed pneumothorax – 9, pelvic fracture – 4); injury was extremely severe, with probability of lethal outcome > 30 %.
After surgical treatment, artificial lung ventilation was prolonged. Considering the severity of condition in ICU, medical sedation was continued for analgesia and synchronization with respirator. Symptomatic therapy was prescribed: antibiotics cephalosporins, blood loss correction (packed red blood cells – 5 ml/kg, fresh frozen plasma – 10 ml/kg), infusion therapy with saline solutions, analgesia (promedol), introduction of protease inhibitors, hemostatic therapy, diagnostic and sanitation bronchoscopy, enteral nutrition with nasogastral probe.
In the period of probable complications (the days 3-10) – on the 3rd day in our case – some negative trends were identified: increasing intoxication, appearance of disadaptation elements with respirator, increasing respiratory failure. The control X-ray examination of the thoracic organs identified a collapse of the right lung and pneumothorax that required for additional draining for the right pleural cavity (Fig. 2), active (during 24 hours) and then passive aspiration (Bulau system) for lung spreading. Pneumothorax was not corrected completely on the first day, with a parietal cavity about 1 cm in the place of right lung apex. Posttraumatic infiltration was in the region of inferior lobes on both sides and apex to the right, more intense to the right – posttraumatic pneumonia. The lung spread completely with regression of the inflammatory process.

Figure 2. The patient Z., age of 8. X-ray study and CT of chest on the 3rd day after admission – collapse of 2/3 of the right lung and drain installment.

After hospital admission, sinus tachycardia and a trend to hypotonia were identified. Sinus tachycardia was persistent and a trend to hypertension appeared with correction of deficiency of circulating blood volume, metabolic and water-electrolytic disorders. ECG showed incomplete blockade of the right bundle branch. ECHO did not find any abnormal changes. Appearance of such rhythm disorders can be one of the signs of heart contusion. Dynamic examination (ECG, ECHO – no abnormal changes over time, cardiospecific enzymes were within the normal range) did not confirm this assumption. The heart contusion diagnosis was withdrawn.
On the sixth day, Bjork inferior tracheostomy was conducted owing to necessity for prolonged artificial lung ventilation, medical and diagnostic bronchosanitation. Bronchial sanitation was conducted within the whole period of ALV (2-3 times per day according to indications).
The antibiotic was changed after 7 days. Also the use of anticoagulants, antisecretory and antioxidant agents was continued. Also bronchial spasmolytics and mucolytics were used. Infusion therapy was continued with consideration of enteral nutrition with correction of electrolytes within the volume of daily norm.
Some positive trends and decrease in intensity of the inflammatory process were observed at the background of intensive care: normalizing temperature and leukocytosis, disappearance of infiltrative changes in the right lung, regression of respiratory insufficiency. Respiratory support was reduced as planned, with gradual transition from controlled modes of ALV to secondary ones and independent breathing. Consciousness level restored to 14 points according to Glasgow Coma Scale. Cerebral CT showed the disappearance of edema in the right hemisphere and lysing of hemorrhagic focus of contusion in the right temporal lobe.
On the 13th day, the child was switched to independent breathing with the tracheostomy tube. The pleural drain was removed after thoracic X-ray examination (pneumothorax was corrected, the lungs were spread; some residual subsegmentary infiltrative changes were in the right lung) (Fig. 3).

Figure 3. The patient Z., age of 8. Chest X-ray study and cerebral CT with positive time trends on the day 17.

On the day 17 after the injury, clear consciousness restored, independent breathing became adequate, the muscular tone became good. Swallowing act did not change. The tracheostomy tube was removed. At admission, the neurological status included the left-sided hemiparesis, which regressed completely on the days 21-23.
Additional examination and dynamic X-ray control were conducted: ECG, ECHO, DS of lower extremity vessels (thrombosis of sural veins in the legs), DS of vessels in the left upper extremity, cerebral and thoracic CT.
Along the whole period of the treatment, the girl was examined by the pediatric surgeon, the neurosurgeon and the traumatologist. The additional consultation was performed by the ophthalmologist, the pediatric cardiologist and the neurologist.
The plaster bandage was removed from the left upper extremity after 26 days. The control X-ray examination was conducted. It showed the recovery of the axis of the humerus and satisfactory condition of the bone fragments (Fig. 4).

Figure 4. The patient Z., age of 8. X-ray study of the left ulnar joint on the day 28 after admission – consolidating fracture of humerus and ulnar process.

The important component in treatment of patients with polytrauma is early initiation of the complex of rehabilitation procedures. They are initiated in the resuscitation room: respiratory gymnastics, vibromassage, remedial gymnastics (with gradually increasing load), staged vertical positioning and others. After plaster removal, remedial gymnastics was continued in the pediatric traumatology unit and was oriented to recovery of range of motions in the left upper extremity.
On the 29th day, the child (her condition was of middle severity) was transferred for further treatment and rehabilitation to the profile unit. She was 23 days there and received the additional treatment: physical treatment, remedial gymnastics. The sufficient range of motions was achieved in the left ulnar joint: extension was full, flexion was 90° actively and 75-80° passively. At the moment of discharge, the child could walk with full load to her lower extremities, the range of motions in the hip joints was full and painless, the fractures united.
The child was discharged in satisfactory condition after 52 days (Fig. 5).

Figure 5. The patient Z., age of 8. Functional result on the day 50 at the moment of discharge.

CONCLUSION

The multidisciplinary approach for treatment of catatrauma allows optimizing the diagnosis of common injuries and determining the volume of required treatment. Subsequent surgical interventions for thoracoabdominal organs and the extremities gave the good result in the specialized facility.

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.

REFERENCES:

1.      Agadzhanyan VV, Agalaryan AKh, Ustyantseva IM, Galyatina EA, Dovgal DA, Kravtsov SA et al. Polytrauma. Treatment of children. Novosibirsk: Nauka Publ., 2014. 244 p. Russian (Агаджанян В.В., Агаларян А.Х., Устьянцева И.М., Галятина Е.А., Довгаль Д.А., Кравцов С.А. и др. Политравма. Лечение детей. Новосибирск: Наука, 2014. 244 с.)
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