POLYTRAUMA IN CHILDREN. A CASE OF SUCCESSFUL TREATMENT OF HEART CONTUSION
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Closed chest injuries are accompanied by heart damages in 70 % of cases, with lethal outcomes in 45-62 %. Lately diagnosed cardiac injuries are about 55 % of cases and are associated with severity of concomitant injury [1, 2]. Commonly, closed cardiac injuries are identified only during postmortem examination [3, 4].
Heart contusion is a primary traumatic myocardial injury, which appears immediately after trauma, and is conditioned by direct mechanical impaction to the chest and the heart. Contusion results in a myocardial injury with one or several regions of hemorrhage into the cardiac muscle or under epicardium (endocardium) with following development of reparative processes around the region of contusion [1-5]. Injuries after blunt cardiac trauma are divided into primary traumatic injuries appearing immediately at the moment of trauma or within the nearest time after it (mechanical impact), or secondary traumatic ones (metabolic posttraumatic disorders) [5]. Cardiac contusion diagnostics is based on the clinical data, dynamic results of electrocardiography [1, 5, 6], echocardiography [1] and dynamic trends of cardiac specific laboratory values (creatine phosphokinase, troponin I and troponin T).
The available literature includes only some limited data about heart contusion in children, with some individual cases of diagnostics of posttraumatic myocardial infarction in a child with traumatic brain injury [7]. In 2000-2009 in our clinic we carried out management for 102 patients (age of 1-15) with polytrauma including 29 children with thoracic injuries with polytrauma (28.4 %). 26 children (89.6 %) suffered from road traffic accidents, 3 children (10.4 %) – after fallings from height. Among 29 children, closed heart injuries were identified only in 2 patients [8]. Therefore, heart contusion in children is quite rare. However, untimely diagnostics or timeless therapy for heart contusion significantly worsens predicted outcomes in such patients.
A girl (age of 3) was admitted to the pediatric admission department of Clinical Center of Miners’ Health Protection. The transfer was made by the emergency team 20 minutes after the falling from the fourth floor of a residential house. The first-aid station informed the duty team about admission of the critically ill patient. As result, intensive care was initiated from the moment of admission.
The state was severe upon admission. The severity of the state was conditioned by traumatic shock. There was a soporific state. AP was 114\70, RR – 28 per minute, HR – 120 per minute. The skin was pale. There were some bruises of cyanotic color in the region of the left shoulder, the right forearm at the anterior medial surface, and in the region of the right and left legs. There was an extensive bruise in the region of the left hip along the lateral surface. The chest was of regular shape, with an extensive bruise and soft tissue edema to the left along the lateral surface from the axillary region to 12th rib, with transition to the lateral surface of the anterior abdominal wall to the iliac wing. There were some flat lung sounds. Auscultation showed suppressed breath sounds to the left along the lateral surface and along the anterior surface in the lower departments. Heart tones were muffled, with correct rhythm. The abdomen was slightly distended, tense during palpation, with an extensive bruise along the lateral surface. It was impossible to estimate peritoneal symptoms. The urina was discharged through the catheter (yellow color, transparent).
Upon the admission the child was examined by the neurosurgeon, the pediatric orthopedist-traumatologist, the pediatric surgeon and the pediatric intensivist. Immediately after the primary examination the child was transferred to the emergency operating room. The surgical intervention was carried out: diagnostic laparoscopy, coagulation of the ruptured splenic capsule, abdominal sanitation, draining. For the left upper extremity the pediatric orthopedist-traumatologist applied the soft fixing elastic dressing by the type of Smirnov-Weinstein. After the emergent surgical intervention the additional examinations were conducted:
– Cerebral MSCT: no pathologic changes in the brain substance.
– Chest MSCT: left-side pneumothorax with collapsing left lung (up to 4 mm in the apical departments, up to 4.9 mm in the anterior departments). Contusion of the upper lobe of the left lung. Some infiltrative changes (patterns of aspiration) in the lower posterior departments of the left lung. Decreasing pneumatization in the upper regions of the right lung (Fig. 1).
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Figure 1 Chest MSCT. Left lung contusion
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Figure 2 ECG at admission
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– X-ray examination of the left humerus and the ulnar joint: the transverse fracture in the distal one-third of the left humerus, without displaced fragments.
– ECG: sinus rhythm, HR – 140 per minute, declination of cardiac electric axis leftwards.
The diagnosis was made after the additional examination: “Polytrauma. Closed traumatic brain injury. Mild cerebral contusion. Closed thoracic injury, left lung contusion, minimal pneumothorax to the left. Heart contusion? Closed fracture of the left humeral bone at the border of the middle and distal one-third, without displacement. Closed abdominal injury. Ruptured splenic capsule, intraperitoneal bleeding. Liver contusion. Pancreatic gland contusion. Multiple bruises of thoracic soft tissues to the left, bruises of anterior abdominal wall, of upper and lower extremities. Blood and gastric content aspiration to the tracheal bronchial tree. Traumatic shock of degree 1”.
After the surgical intervention and the additional examination the girl was transferred to the pediatric room of the intensive care unit. Upon admission to the ICU the child’s state was severe and was conditioned by traumatic shock and water electrolytic and metabolic disorders. Artificial lung ventilation was continued with the modes IPPV, Fr – 24, Vt – 90.0, FiO2 – 0.4.
The patient’s state was stabilized within 24 hours at the background of the complex intensive care. Extubation was performed 18 hours after admission to the ICU. The breathing was independent and adequate.
Cardiac ultrasound was conducted. It showed some disorders of contractile function of the left ventricle, with regions of disorders of local contractility in view of hypokinesia of cacuminal segments and akinesia of the interventricular septum. Left ventricle ejection fraction decreased to 53 %. The pediatric cardiologist gave some consultations. Heart contusion was confirmed. Heart contusion diagnostics was based on the clinical data, the results of dynamic changes of the electrocardiogram, and echocardiography data.
The clinical data for 4 days included muffled heart tones, tachycardia up to 140 beats per minute, arterial pressure lability with some events of increase up to 120-125/70-80 mm Hg with further normalizing AP to 100-90/60-55 mm Hg and HR up to 100 per minute. The borders of deep cardiac dullness were not extended during percussion. The liver was 2 cm beyond the border of the costal arch, without edema.
The electrocardiogram showed declination of electrical axis leftwards. It is not common for a pediatric ECG; however, no infarction-like changes were found (Fig. 2). On the second day the electrical axis became normal. The deflections III and AVF included Q wave and ST segment elevation by 1 mm with positive T wave. It was described as infarction-like changes in the lower wall of the left ventricle (Fig. 3). Later this group of deflections showed some trends, which are common for the course of myocardial infarction in the lower wall of the left ventricle: ST segment gradually returns to the isoline, with formation of negative T wave. On the eighth day the electrocardiogram showed a deep negative T wave in the deflection III (Fig. 3). Some specific changes were in the thoracic deflections (Fig. 4). ST segment elevated on the fifth day. Such elevation persisted within several days (Fig. 4). Disorders of repolarization processes were interpreted as the course of heart contusion. Repolarization processes in all deflections normalized only on 22th day.
Figure 3
Dynamic changes of the electrocardiogram. The infarct similar changes in lower wall of the left ventricle: a) 2nd day; b) 3rd day; c) 4th day; d) 8th day
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b 
c 
d
Figure 4
Dynamic changes of the electrocardiogram. The disorders of repolarization processes in thoracic derivations: a) 5th day; b) 6th day; c) 8th day; d) 11th day
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b 
c 
d
According to echocardiography data, contractile function of the left ventricle normalized only on 8th day. Ejection fraction increased to 69 %. Hypokinesia regions disappeared.
The characteristics of the laboratory data are presented in the table. One should note significant increase in activity of cytolysis enzymes as result of traumatic cellular destruction at admission. Cardiospecific MV fraction of creatine phosphokinase was 63 mmol/l at admission (24 mmol/l is the reference), and it was at high level over time, indirectly indicating a myocardial injury.
| Table | ||||||||
| The dynamic changes in laboratory values of the patient A., age of 3, for the treatment period | ||||||||
The complex ICU treatment included infusion-transfusion, antibacterial, antisecretory, hemostatic, disaggregation, anticoagulant, nootropic and analgetic therapy. Also therapy for heart contusion was conducted that included preductal MV retard (trimetazidine), 1 table – 0.035 g, the dosage of ½ table 1 time a day; ATE inhibitor enalapril, 0.1 mg/kg of body mass per a day, divided by two intakes, with gradual increasing to 0.2 mg/kg of body mass per a day (two times a day); beta-adrenergic blocking agent: egiloc, 6.25 mg two times a day, each 12 hours, for 30 days.
On 4th day after the surgical intervention one abdominal drain (small pelvis) was removed. The second drain (splenic angle) was removed on 5th day. From 3rd day minimal enteral nutrition with slow extension of nutrition volume was initiated. At the background of the realized therapy the positive dynamic characteristics of left lung contusion was observed, as well as retrogression of respiratory insufficiency with improvement of radiologic and paraclinical values. The rehabilitation procedures and physiotherapy were initiated in the pediatric intensive care unit at the background of positive changes in state of the child. On 22nd day the patient was transferred to the department of pediatric surgery (Fig. 5). The treatment was during 15 bed days.
Figure 5
The day 22. Transfer from the intensive care unit to the pediatric surgery unit
The child’s state was satisfactory per the day of discharge (the day 37). The hemodynamic parameters corresponded to the following values: AP 100/60 mm Hg, HR 100 per minute, SpO2 – 99 %, the limits of deep cardiac dullness are common for the age, heart tones are loud; respiratory arrhythmia. There were no disorders of rhythm and conduction during daily ECG monitoring. The recommendation for outpatient treatment was preductal MV under supervision of pediatric cardiologist.
CONCLUSION
Transportation of a child with polytrauma to the multiprofile hospital within “golden hour” allows timely realizing specific assistance and significant reducing risk of possible complications.
Children with thoracic injuries require maximally fast complex examination for exclusion of heart contusion that includes clinical examination, instrumental methods of examination (electrocardiography, echocardiography), laboratory diagnostics with estimation of dynamic changes of cardiospecific enzymes from the moment of admission.