Federal Scientific Clinical Center of Miners’ Health Protection, 

Leninsk-Kuznetsky, Russia

The rate of traumatic brain injury is 30-50 % among other injuries to the human body. According to WHO data this rate increases 2 % annually.

The rate of traumatic brain injury is higher in children in comparison with adults [5, 6]. Cranial and cerebral injuries account for 21-75 % [11] of all injuries in children and take the leading place according to all locations of injuries requiring admission [1, 2, 3]. Despite of dominance of a mild traumatic brain injury in most cases, 60-80 % of cases are associated with different consequences. Negative influence of traumatic brain injury is worsened with age, and it determines disarrangement of integrative activity of the brain, evolving vegetative, intellectual and other disorders preventing appropriate development and social-labour adaptation [5].

The main causes of accidents in infants and young children are falling from a swaddle table, a bed, a baby carriage or from the hands of parents. Falling from greater height is more common for preschool children: through the window, from ladder, a tree or roof. With increasing age the incidence of sport injuries increases. The rate of injuries is 2-3 times higher in boys compared to girls. It is explained by specific parenting, higher mischief, “heroism” and boys’ interest in cars and other mechanisms. The age determines the level of consciousness and, as result, of behavior. As result, children of different age groups are amenable to injuries. Injury rate is higher in children of preschool and primary school age. The greatest proportion of injuries appears in the second half of the day, when children go home.             

An outcome of severe traumatic brain injury mainly depends on timely emergent medical assistance. Medical procedures are usually initiated at accident site or in the ambulance car. It is wise to transfer children with traumatic brain injury to special neurosurgery and traumatology centers providing comprehensive and adequate treatment.

Objective – to perform the analysis of traumatic brain injuries in children with polytrauma in conditions of the specialized trauma center.

MATERIALS AND METHODS

The materials are based on the retrospective analysis and the demographic analysis of traumatic brain injury in children with polytrauma (106 patients) treated in the specialized trauma center, with use of 20 years of practical experience of Clinical Center of Miners’ Health Protection. The analysis included the 10 year period (2003-2013) (table 1).

Table 1
Distribution of children with traumatic brain injury according to gender and age

There were 67.9 % of the boys and 60.4 % of the children at the age of 7-14. At the admission department all patients received complex clinical examination performed by the physicians of the team on-duty. The main combinations of injuries were traumatic brain injury and abdominal injury – 67.8 %, traumatic brain injury and skeletal injury – 58.2 %, traumatic brain injury and chest injury – 37.1 %. The diagnosis of cranial and cerebral injuries was made on the basis of clinical and instrumental examination (cerebral MSCT).     

Middle and severe cerebral contusions were found in 46 patients, intracranial hematoma – in 16. The clinical presentation included the following groups of the symptoms: consciousness disorders, cranial nerve injuries, focal lesions of the brain, stem and meningeal injuries. The consciousness level was estimated with Glasgow Coma Scale. Road traffic injuries prevailed according to the injury mechanism (82.8 %). Most children were admitted in severe (94.3 %) and extremely severe (5.7 %) state. Different types of depressed consciousness were found in all patients: stupefaction (51.9 %), spoor (14.2 %), coma (34 %).          

8 children died (7.5 %). All of them were in extremely severe state and with evident disorders of consciousness (coma II-III).  

The tactics of surgical treatment was defined on the basis of complex examination of the patients with polytrauma: objective examination, clinical radiologic data, laboratory examination.

There were 28 surgical interventions: removal of impacted fragments of the cranial vault (6 patients), removal of intracranial hematoma (18 patients), internal decompression of the brain (6 patients).

 

RESULTS AND DISCUSSION

All patients were distributed into two groups: deceased and survived (table 2).

Table 2
Characteristics of patients with traumatic brain injury according to outcomes

There were 98 survived patients (92.5 %). Lethal outcomes were in 8 patients (7.5 %).

Closed traumatic brain injury was found in 58.3 %.

The hospital period was from 30 minutes to 3 days from injury moment.  

Most patients were admitted to the hospital within 3 hours from injury moment (49 patients, 46.2 %). 42 patients (39.6 %) were admitted within an hour after injury (table 3).

Table 3
Hospital admission intervals from the moment of injury

The table 4 demonstrates the distribution of the patients according to time of neurosurgical interventions from the moment of admission.

Table 4
Distribution of patients according to surgery time

Most patients were operated within 2 hours after admission (25 patients, 89.3 %). The indications for surgical treatment in acute period of traumatic brain injury are:

-          open cranial and cerebral injury; primary surgical preparation of the wound is performed. The volume and site of preparation are identified after radiologic examination of the skull. In case of splintered or depressed fracture one should identify a site for correcting the depression by means of reposition or removal of fragments;           

-          closed depressed fracture of cranial bones – reposition of fragments;

-          intracranial hematoma of any location; One should perform skull trepanation with low invasive surgical techniques; 

- extensive crushing regions; bone plastic or decompressive trepanation is required [7, 8].

Neurosurgical technique has some specific features relating to children. The characteristics of pediatric anatomy and development determine specificity of neurosurgical manipulations and approaches. It mostly relates to young children (0-4 years) [9, 10].

At all stages of the surgery the special attention is given to proper hemostasis, since even insignificant blood loss can be critical because of low volume of circulating blood.

Pathogenetic therapy was carried out together with surgical treatment.

The conducted therapy was oriented to decreasing intracranial pressure, secondary cerebral edema, prevention of brain hypoxia and normalizing the cerebral metabolic processes.

The most common injury mechanism was pedestrian accidents involving children (58.5 %). Speedup or decelerations in a vehicle were found in 24.5 % (table 5).

Table 5
Distribution of cases according to injury mechanism

Most children with polytrauma were admitted in severe (94.3 %) and extremely severe state (5.7 %) (table 6).   

Table 6
State of patients in different age groups

Different types of depression of consciousness were found in all patients (table 7). Apparent disorders were found in 48.2 %.

Table 7

Distribution of patients according to consciousness level and treatment outcomes at admission

Among the patients with lethal outcomes 8 patients were admitted in coma II-III.

Severe traumatic brain injury as the main component of polytrauma took place in 43.6 % of the suffered children.

Depending on an outcome of traumatic brain injury all patients were distributed into five groups (recovery, nervous mental dysfunction of mild and severe degrees, vegetative state, death). Most patients were discharged with signs of mild nervous mental dysfunction (58 patients, 54.7 %). Recovery was observed in 25 (23.5 %) patients. 8 patients died (7.5 %). The cause of the lethal outcomes was diffuse edema with development of secondary disorders of cerebral circulation in basal stem departments of the brain.

Therefore, the choice of active surgical tactics depended on clinical radiologic data that allowed identifying functional structural disorders. The targeted direction of surgical interventions was associated with identified pathologic formations (compressing factors, primary or secondary focuses of brain softening [7, 8 , 9]. Low invasive surgical techniques are preferable.

CONCLUSION

1.      Treatment of patients with traumatic brain injuries with polytrauma is to be performed in conditions of a specialized medical facility with possibility for rendering complex surgical, traumatological and neurosurgical assistance.

2.      Road traffic injury is the main injury mechanism in children: pedestrian accidents (58.3 %), acceleration or deceleration in a vehicle (24.5 %).

3.      Traumatic brain injury as the main component of polytrauma was in 43.6 %. The outcomes at discharge were mild nervous mental dysfunction (54.7 %), recovery (23.5 %), death (7.5 %).