SOME PROBLEMS OF TREATMENT OF POLYTRAUMA IN CHILDREN

SOME PROBLEMS OF TREATMENT OF POLYTRAUMA IN CHILDREN

Sinitsa N.S., Kravtsov S.A., Agalaryan A.Kh., Obukhov S.Yu., Maleev V.A.

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

Polytrauma is the most dangerous trauma of the child’s body resulting in high mortality (5-15 %). The modern medical equipment promotes the successful early diagnosis of injuries in polytrauma. Fast identification of accurate diagnosis and appropriate therapy solve the question of the patient’s life or death.
Currently, the group of the interventions, which are conducted according to the absolute indications, i.e. operations saving the patient’s life, has been defined enough sufficiently. These are the interventions for intraabdominal bleedings, injuries to parenchymal organs, intestinal damages, tension hemopneumothorax, cerebral and spinal cord compression, surgeries for detached extremities with ongoing bleeding. All these procedures are anti-shock and are carried out within the shortest time intervals. But as for locomotor injuries, osteosynthesis should be conducted within early time after trauma.
However underestimated child’s condition and inappropriate diagnostics can cause some errors and complications, inadequate management and longer treatment. A diaphragm rupture is identified in 0.5-5 % of cases with associated injury. It is characterized by difficult diagnosis owing to condition severity and concomitant thoracic and abdominal injury.
Objective – to demonstrate the errors and the complications developed during diagnostics and treatment in a child with polytrauma.
Materials and methods. The study describes a case of polytrauma treatment in the child (age of 14) with the associated thoracic and abdominal injuries, fractures of pelvic bones, the clavicle, the forearm and traumatic brain injury. The results of the X-ray examination and the surgical treatment of the skeletal trauma are given.
A common mistake in the non-specialized facilities is described. It is possibly associated with insufficient experience of specialists: underestimation of trauma severity and the patient’s condition, non-use of ISS.
Results. The child received the treatment during 40 days including 18 days in the intensive care unit (traumatic pneumonia developed there) and 23 days in the profile unit. The child was discharged in satisfactory condition after the surgical treatment of thoracic organs and the extremity bones, complex infusion therapy, long term artificial lung ventilation.
Conclusion. The uniform approach to estimation of trauma features and understanding the characteristics of the pathologic process course allow developing the coordinated tactics during carrying out the intensive care and surgical management with the principle of forward-looking treatment.
Some mistakes were done during the treatment in the level 2 facility: underestimated condition severity, a non-diagnosed diaphragmatic rupture, a lung injury. Appropriate anti-shock therapy was not conducted, blood loss was not corrected and fixation of the damaged bones was not realized. A late demand for the specialized care was noted that resulted in pneumonia.
The good outcome was achieved with the timely diagnostic measures in the complex subsequent surgical interventions within a single surgical session for chest organs, the abdomen and the extremities in the level 1 facility.

Key words: polytrauma; children; diaphragmatic injury; osteosynthesis

The rate of injuries has not been decreasing, but even has beenincreasing due to continuous technical progress, increasing amount of vehicles and other infrastructures, with increasing amount of patients and higher severity of trauma, especially in children. The values of postinjury mortality are 10.7 per 100,000 of the population in the Russian Federation. Polytrauma is the most dangerous and life-threatening injury to the child’s body which is characterized by the highest mortality (5-15 %) [1-4]. The main causes of the mortality are road traffic accidents. Most patients admitted to the hospital are in severe and extremely severe condition, with events of traumatic shock.
The treatment of this category of the patients is characterized with specific complexity, multiple stages, strict consequence and individuality. The principles of treatment of adults and children are identical, but one should know the age-related features of treatment of children with injuries. The special knowledge of the unique anatomy and physiology of the child’s growing body is required. The child’s body is characterized by high elasticity. Internal injuries without evident external signs are possible. Children have the high risk of severe injuries owing to proximity of location of the vital organs to the body surface and between them, the unfavorable ratio “the head/the body”, low body mass and low stature. The clinicians must know and consider all of these for selecting a strategy when estimating severity of injuries, patient’s condition and management principles for children with polytrauma.
The high attention to this problem favored the development and implementation of the big complex of the organizational, diagnostic and management measures [1, 3, 5-8]. Treatment of patients with polytrauma should be conducted in conditions of the specialized multi-profile trauma center of level 1. If a child is admitted to level 2-3 trauma centers, then only urgent care is given according to the vital indications (bleeding arrest, initiation of anti-shock intensive care). Within 24 hours, the child has to be transferred to the level 1 trauma center. The modern possibilities allow the continuation of the intensive stage of treatment by the specialized medical team. It provides safe transportation.
In each individual case, the physician should solve the multidisciplinary task: estimation of patient’s condition, choice of optimal diagnostic techniques, assessment of risk of the proposed surgical manipulations, selection of the most efficient treatment techniques. That's exactly why the treatment of such patients should include participation of physicians of different specialties (traumatologists, intensivist, surgeons, neurosurgeons, cardiologists, pulmonologists, endoscopists etc.) [9].
The principle of the individual approach to choice of management for polytrauma manifests in in its entirety. Not only the time of a manipulation or surgery is determined [3, 5, 6], but also their volume, which should correspond to a degree of disorders of the vital functions, to compensatory capabilities of the body of the patient, and to surgeon’s experience. In each individual case, the choice of management is determined by three main factors: general condition of the patient, location and characteristics of closed or opened fractures, and a type of a combination of injuries.
A diaphragm rupture occurs in 0.5-5 % of cases with associated injury. It is characterized by diagnostic difficulties relating to condition severity and concomitant thoracic and abdominal injury. The diaphragm rupture is treated only with urgent surgical intervention [8].
Concerning the locomotor system injuries, the authors’ opinions are different. Final treatment of injuries to the extremities in children with polytrauma is usually performed within 24 hours after trauma.
Early stabilization of fractures decreases the pain and the risk of secondary or neurovascular injury. Obviously, the conservative treatment techniques for multiple fractures in adults and children are the most simple and the safest, but sometimes not the very best for patients with polytrauma. This category of patients is associated with other criteria for selecting the treatment technique and conditions of care of each patient: amount of fractures and severity of early and late complications, duration of bed rest and results of treatment [10].
Initially, a soft approach to surgical treatment was observed, with the 4:1 ratio of conservative and surgical techniques for polytrauma. It was considered that locomotor system surgery was contraindicated in multiple fractures with shock of a possibility of shock and fat embolia. The main techniques were plaster immobilization and skeletal traction. However multiple injuries cause some difficulties for care, decrease in patients’ mobility, resulting in bedsores, pneumonia and other possible complications.
Currently, the surgeon has the wide choice of interventions for fracture stabilization: transosseous osteosynthesis with external devices, external fixation and the variants of intramedullary osteosynthesis with locking and without it. Flexible intramedullary osteosynthesis has become the universal technique for treatment of fractures in children [7, 11]. The significant advantages of the flexible intramedullary nails have been recognized in comparison with other fixation systems such as intramedullary locked nails, plates and external fixators, although each system has the specific indications. Fractures of the metaphysis and the epiphysis are mainly treated with K-wires. Some cases require for additional or alternative application of an external fixator. Depending on a fracture type, its features and child’s age, opened reposition with internal fixation with screws or plate osteosynthesis are conducted. Fractures of the diaphysis are mainly fixed with flexible intramedullary nails. However the main goal is early final osteosynthesis of fractures of the extremities.
In our multi-profile facility, we adhere to the principle of early surgical intervention for bone fractures in children with polytrauma. We observed 101 children with polytrauma. Skeletal injury was in 78 children (77 %). The skeletal injury was the main trauma in 45 children (44 %), TBI – 40 (39 %), abdominal injury – in 12 (13 %), thoracic injury – in 4 (4 %) [7].
Objective – to demonstrate the possibilities of the integrative approach during diagnostics and treatment in a child with polytrauma.
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, June 19, 2006, No.266), with receiving the written consent from the child’s parents for participation in the study and approval by the local ethical committee of Regional Clinical Center of Miners’ health Protection.

The clinical case

The patient S., age of 14, was a passenger in a car, which collided with other car. After the road traffic accident, the child was transferred to the level 2 medical facility.
The patient’s condition was considered as severe, the consciousness was changed according to clouding type. Respiratory insufficiency and a trend to hypotonia were found. The preliminary diagnosis: “Polytrauma. Multiple skeletal injury, thoracoabdominal injury, traumatic brain injury, shock 2”. At the background of intensive care (infusion therapy, analgesia), the X-ray examination of the chest, the pelvis, the forearm and the cranium was carried out.
Diagnostic laparoscopy was conducted under endotracheal narcosis. It showed the hematoma in the region of the hepatic angle of the colon. 30 ml of the blood were in the abdominal cavity. No signs of continuing bleeding were identified. A drain was installed in the subhepatic space. Primary surgical preparation of the wounds of the head and of the right ulnar joint was made. Bone reposition was not performed. Plaster immobilization of the upper right extremity was performed. In the postsurgical period, at the background of hemodynamics stabilization, restoration of the muscular tone and clear consciousness, the child was extubated and switched to independent breathing. The volume of infusion therapy was 2,100 ml per day (saline and 5 % glucose) Diuresis was 410 ml.
The diagnosis was made: “Polytrauma. Closed thoracic injury, a closed fracture of the ribs 9, 10 and 11 to the right. A closed fracture of the middle one-third of the left clavicle with displacement of fragments. A closed fracture of the right iliac bone, a fracture of the right ischial bone. A closed fracture of the distal one-third of the bones of the right forearm with displacement of fragments. Blunt abdominal injury, contusion of the anterior abdominal wall. Brain concussion, contused wounds in the occipital region. Traumatic shock 3”.
So, the patient’s condition was severe. For further treatment, he was transferred to the level 1 trauma center.
One should note a common mistake at the initial level of treatment in the level 2 medical facility. Possibly, it was associated with insufficient experience with these issues: underestimated degree of injuries and severity of condition. By the way, such outcomes can be prevented in 25-30 % of cases, if the uniform approach to estimation of trauma is used.
Among the high number of the scores for estimating severity of condition, the most popular one is ISS (Injury Severity Score) as the simplest and available in any conditions. It is almost the exclusive anatomical system of estimation, which closely correlates with condition severity, ALV duration, hospital stay and mortality.
In the reviewed case, even the simplest calculation could be used: chest injury (lung contusion, rib fracture, clavicle fracture) – 9 points, pelvic fracture – 9 points, right forearm fracture – 4 points; total – 22 points. The sum of 16-24 points means severe condition of a patient, with a possibility of the lethal outcome exceeding 20 %. It is without consideration of blood loss. Blood loss can achieve 2-4 l in closed fractures of the pelvis, 1.5-3 l – for hip fractures, 0.5-1 l – for the upper extremity fractures. The blood loss increases gradually, during 2 days. As a rule, it is internal hematomas. The priority in urgent critical care is removal of life-threatening consequences of polytrauma – bleeding, hypoxia, respiratory disorders, blood circulation disorders, metabolism disorders. This axiom was not considered in our case. The principle of outrunning treatment was not used. The correction of polytrauma consequences was insufficient. The child was switched to independent breathing. All premises for further worsening condition were made. The independent call of the specialized team was absolutely correct, but a little behind time.
The child was transferred to the level 1 trauma center 26 hours after the injury (not within the first 24 hours) by the specialized team of our center including the intensivist and the traumatologist. The transfer time was 40 minutes. The Kashtan anti-shock suit was used. Infusion therapy was used during transportation (saline, 6 % HES, total volume was 700 ml), respiratory support with moistened oxygen insufflation (5 l/min), narcotic analgetics. The general condition at the moment of admission was without worsening. The condition was severe due to the injury, the course of traumatic shock, experienced acute blood loss, posthemorrhagic anemia, pain syndrome.
The team of the physicians examined the patient at the moment of admission (the intensivist, the pediatric traumatologist, the pediatric surgeon, the neurosurgeon). The additional examination was conducted: cerebral MSCT – no brain or cranial bones pathology; chest organs – fractures of the ribs 9-11 to the right, minimal hemopneumothorax, right lung contusion, high position of the cupula of the diaphragm to the right; X-ray examination and MSCT of the pelvic bones – a longitudinal fracture of the iliac crest, a fracture of the ischial bone; X-ray examination of the left clavicle – a fracture of the middle one-third of the left clavicle with displacement of fragments; X-ray examination of the right forearm – a fracture of the distal one-third of the forearm bones with displacement of fragments. ECG and echocardiography were conducted (Fig. 1).

Figure 1. The X-ray image of the chest, the pelvis and the extremity at the moment of admission


The examination identified the posthemorrhagic anemia (Hb – 92 g/l; Ht – 27.6 %). The child was admitted to the intensive care unit for conduction of intensive presurgical preparation. The antibiotics were prescribed (generation 2 cephalosporins as the start therapy). Blood loss was corrected (packed red blood cells of 5 ml/kg, fresh frozen plasma – 10 ml/kg). Infusion therapy with saline solutions, analgesia and introduction of protease inhibitors were continued.
3 hours and 5 minutes after admission and realization of presurgical preparation, the patient was urgently transferred to the surgery room. Narcosis was endotracheal. Recurrent diagnostic laparoscopy was conducted. It showed a rupture in the right cupula of the diaphragm in the central part (up to 10 cm). The surgical approach was extended. Anteriolateral thoracotomy was conducted in the sixth intercostal space to the right, the suture of the rupture of the right cupula of the diaphragm by type of duplicatura, the suture of the rupture in the lower lobe of the right lung with individual interrupted sutures, right pleural cavity draining in the fourth intercostal space along the axillary line.
On behalf of realization of intensive care, fractures of the extremities are often missed and are treated in late period. In our case, the child received the single-stage opened reposition of the left clavicle and external osteosynthesis. Opened reposition of the radial and ulnar bones in the distal one-third of the right forearm and K-wire fixation were conducted. For reduction of surgery time, pelvis osteosynthesis was not performed, but K-wire was guided through the calcaneal bone and the skeletal traction system was applied. The surgery lasted for 2 hours and 37 minutes (Fig. 2).

Figure 2. The X-ray image of the chest, the pelvis and the extremity after surgical treatment

The diagnosis was clarified on the basis of the conducted examination and the surgical treatment: “Polytrauma. A closed chest injury. A rupture in the right cupula of the diaphragm. A rupture in the lower lobe of the right lung. A complicated fracture of the ribs 9-11 to the right. Hemopneumothorax to the right.
A blunt abdominal injury, abdominal wall contusion, contusion of the right lobe of the liver, subserous hematoma of the hepatic angle of the colon. Traumatic brain injury. Brain concussion. Wounds in the right occipital region.
A closed fracture of the right iliac bone, a fracture of the right ischial bone. A closed fracture of the middle one-third of the left clavicle with displacement of fragments. A closed fracture of the distal one third of both bones of the right forearm with displacement of fragments. Wounds in the right ulnar joint. Traumatic shock 3”.
ISS was 27 (lung contusion – 9 points, fracture of pelvic bones – 9 points, diaphragmatic rupture – 9 points). The injury was extremely severe. The possibility of lethal outcome was more than 30 %.
}After the surgical treatment, ALV was continued according to the safe ALV principle with pressure control (provision and support of targeted inspiratory peak flow during the whole time of inspiration, with gradual shift to independent breathing).
During the period of maximal possibility of complications (the days 3-10), the moderate negative time course with increasing intoxication syndrome and persistent respiratory insufficiency were observed on the fifth day. The control R-logic examination of the thoracic organs identified some massive infiltrative changes in the right lung – right-sided multiple segmental pneumonia. Due to need for prolonged ALV and curative and diagnostic bronchial sanitation, the child received Byerk inferior tracheostomy. Bronchial sanitation was conducted during the whole period of ALV (2-3 times per day according to the indications). The antibacterial therapy was changed (reserve antibiotics). The therapy was continued with use of anticoagulants, antisecretory and antioxidant drugs. Bronchial spasmolytics and mucolytics were used. Infusion therapy with correction of electrolytes with the volume of physiological requirements and with consideration of enteral nutrition was performed.
The positive time course in the patient’s condition and decreasing intensity of intoxication syndrome (normalization of temperature and leukocytosis) were observed at the background of the intensive care. The regression of respiratory insufficiency, resolution of infiltrative changes in the right lung and adaptation to independent breathing were noted. Respiratory support was decreased in the planned form, with gradual shift from the controlled modes of ALV to secondary ones. On the 13th day, independent breathing with the tracheostomy tube was initiated. The pleural drain was removed after X-ray examination (Fig. 3). The consciousness was clear. Breathing was adequate and independent. The tracheostomy tube was removed on the 14th day.

Figure 3. The control dynamic X-ray images of the chest on the days 5, 7 and 13 during pneumothorax correction


The severity of condition was average. On the 18th day, the child was transferred to the pediatric traumatology unit, where he stayed for 22 days. The patient received anti-inflammatory treatment, physical treatment and remedial gymnastics.
The child could move three weeks later. He was trained to walk with additional support and without it. The patient was discharged in satisfactory condition in 40 days (Fig. 4).

Figure 4. The patient’s appearance before  discharge

CONCLUSION

1. The uniform approach to estimation of trauma patterns and understanding of the features of the pathologic course allow developing the coordinated management during realization of critical and surgical care based on the principle of outrunning treatment.
2. Some treatment errors (underestimation of the patient’s condition) were made in the non-specialized facility (level 2 trauma center). The diaphragmatic rupture and the lung injury were not diagnosed. Appropriate anti-shock therapy was not conducted. Blood loss was not replaced. Osteosynthesis of the injured bones was not carried out. Specialized treatment was delayed, resulting in pneumonia.
3. The good outcome was achieved owing to the timely diagnostic and curative measures in combination with subsequent surgical interventions within the single surgical session for the thoracic organs, the abdomen and the extremities in the level 1 trauma center.

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