POLYTRAUMA IN CHILDREN. A BLUNT CARDIAC INJURY. A CLINICAL CASE OF INCOMPLETE LACERATION OF LEFT VENTRICLE MYOCARDIUM Vlasova I.V., Vasilyeva N.D., Bogdanov A.V., Sherman S.V.
Regional Clinical Center Of Miners’ Health Protection, Leninsk-Kuznetsky, Russia
Trauma takes one of the leading places in the etiological structure of disability and mortality in children. The rate of pediatric injury rate is continuing to increase. The mortality from injuries is 10.7 per 100,000 of population in the Russian Federation [1, 2].
Injuries to chest cavity organs are related to the most severe types of mechanic injuries and are accompanied by high mortality. According to the literature data, the closed chest injury in children is caused by road traffic accidents (RTA) in 48.1 %, falling from height – in 27.4 % [1. 3]. Mechanic cardiac injuries in blunt chest injury are extremely severe [4]. Among thoracic injuries in children, the incidence of closed cardiac injuries is 7 %, pericardium – 1.3 % [1]. The understatement of the real incidence of closed cardiac and pericardial injuries in conditions of the clinic is expected [1]. One should note that cardiac contusion in patients with closed chest injury is the abnormality, which is difficult to diagnose owing to absence of reliable diagnostic criteria and to polymorphism of its manifestations [5, 6, 7]. Cardiac injuries are various according to their characteristics: from concussion to rupture of chords and valves. Currently, there is not any uniform opinion on forms of closed cardiac injuries and on the generally accepted classification [8]. However most authors agree with presence of at least two types of diagnosed injuries – cardiac contusion and laceration (bursting) of its various structures [8].
Ones of informative clinical manifestations of cardiac contusion are different disorders in cardiac rhythm and conduction. Therefore, timely electrocardiographic study is the important diagnostic tool. The incidence of identification of electrocardiographic changes in cardiac injury is almost 100 % [4, 9]. Also, the changes, which are manifestation of ischemic disorders in cardiac muscle in such injury, are identified [3, 9].
The informative technique for cardiac contusion is ultrasonic diagnosis, which can estimate the intracardiac hemodynamics. Also the decrease in ejection fraction and the increase in the volume of the left ventricle, as well as the increase in pressure in the pulmonary artery are often identified. The use of this technique identifies the disorders of anatomic integrity of the heart and big vessels [9, 10].
Estimation of levels of troponins, creatine phosphokinase, myofibrillar creatine phosphokinase in blood plasma, and N-terminal part of NT- pro BNP is perspective for diagnosis of cardiac contusion in closed blunt chest injury [11, 12].
According to the experience in arrangement of urgent medical care for patients with chest injuries, physicians identify the cardiac contusion significantly later since clinicians pay the first-priority attention to injuries to chest bones and to shock, which often develops in severe trauma [1]. The feature of pediatric injury in 70.6 % of cases present the injuries (contusion and lacerations) with intact rib cage of the chest. Owing to elasticity of bone structures, injuries to rib cage in children are identified in less than one-third of cases. Therefore, cardiac contusion in closed chest injury is often identified in autopsy [13].
According to the above-mentioned facts, the study of semeiotics of heart contusion and variants of the course of this pathology in children is the important topic [1, 4, 15]. The important task is timely diagnosis. Therefore, treatment of patients with polytrauma is necessary to perform in conditions of the special multi-profile center with algorithms for diagnosis and treatment of polytrauma [3].
Objective – to demonstrate a rare case of favorable course of a severe cardiac injury with incomplete laceration of cardiac muscle 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, 19 June 2003, No.266), with written consent from the patient’s parents for use of the data and with approval from the local ethical committee of Regional Clinical Center of Miners’ Health Protection (the protocol No.24, 14 September 2018).
CLINICAL CASE
A boy, age of 1 year and 9 months, was admitted to the pediatric admission unit of Regional Clinical Center of Miners’ Health Protection. He was transported by the emergency medical team 30 minutes after a road traffic injury. The injury characteristics: he was hit by a car riding from the garage; loss of consciousness. The emergency medical station informed the team-on-duty regarding the admission of the critically ill child. Intensive care was initiated from the moment of admission in the pediatric admission unit.
The condition of the child was severe at the moment of admission. The child was consciousness and obtunded. The severity was determined by traumatic shock at the background of the severe thoracoabdominal injury. The skin was pale. There were some scratches and hematomas in the region of the left forearm, the right leg and the anterior surface of the chest.
Breathing was vesicular in the lungs, without rattling sounds. The respiratory rate was 23 per min. Cardiac tones were clear, rhythmical, without noises. The heart rate was 140 per min. Arterial pressure was 85/55 mm Hg.
The abdomen was soft and painful during palpation. There were not any pathological formations in the abdominal cavity during palpation. Rebound sensitivity was doubtful. The lumbar region was without any features. The urine was collected through the catheter; its color was clear. The rectal examination did not find any overhanging and infiltration of intestinal walls. Palpation was painless.
The child was examined by the medical team in the admission unit: neurosurgeon, pediatric surgeon, pediatric orthopedist-traumatologist, pediatric intensivist. The preliminary diagnosis was made: “Blunt abdominal injury with possible injury to abdominal organs; possibility of intraabdominal hemorrhage. Traumatic brain injury, brain concussion. Contusions and scratches on the left forearm, the right leg and the anterior surface of the chest”.
Urgent laparotomy and revision of abdominal organs were conducted. A hematoma was found in the hepatogastric ligament. Hematoma revision, hemostasis and abdominal cavity draining were carried out. Artificial lung ventilation with decreasing respiratory support was performed in the postsurgical period. At the background of restoration of high level of consciousness and satisfactory muscular tone, the child was switched to independent breathing.
The examination was continued after the urgent surgical intervention. Multispiral computer tomography (MSCT) of the brain did not find any abnormality. Chest MSCT showed some infiltrative changes in the superior lobe of the left lung.
While the hemodynamics was stable, without pain in the chest, the results of electrocardiography (ECG) were interesting. ECG description: sinus rhythm, HR – 156 per min., deep Q wave in leads 2-3, AVF and in V4-V6 with slight concordant elevation of ST segment in these leads, with positive T wave. The changes were estimated as infarct-like, with sings of electronegative tissue in the inferior wall and in the apical lateral region of the left ventricle. Events of pericarditis were not excluded (Fig. 1).
Figure 1
ECG at admission.
Echocardiography (EchoCG) identifies some changes: sizes of chambers were within the boundaries of age norms. Ventrical hypertrophy was not identified. Systolic and diastolic functions of the left ventricle (LV) were not disordered. Ejection fraction (EF) was not decreased (the table 1). There were not any structural and functional changes in the valves. Valve leaflets were thin and movable. Mitral and tricuspidal valve regurgitation was within the physiological norms. Ejection in the interventricular septum (IVS) and in the interatrial septum was not identified. The wall defects (5-6 mm depth and 6-7 mm width) in view of semi-concentric furrow were identified on the border of apical and middle segments of LV. The residual thickness of the wall was not more than 1.5-2 mm in this region. The thin parts were hypokinetic. There was a deep defect in the base of lateral papillary muscle (Fig. 2, 3). The anterior wall was without significant changes. Separation of pericardial layers along the posterior wall of the left ventricle was 3 mm (Fig. 4). The conclusion: the signs of incomplete internal semi-concentric rupture of the left ventricle wall. Small amount of fluid in pericardium (hemopericardium).
Table 1
Echocardiography values in primary examination
|
Right ventricle |
1.1 cm |
End diastolic size of LV |
2.8 cm |
|
Thickness of interventricular septum |
0.4 cm |
End systolic size of LV |
1.6 cm |
|
Thickness of posterior wall of left ventricle |
0.4 cm |
Ejection fraction |
75 % |
|
Aortic root |
1.27 cm |
End diastolic volume of LV |
21 ml |
|
Left atrium |
2.1 cm |
End systolic volume of LV |
8.8 ml |
|
Right atrium (B mode) |
2.2 õ 2.3 cm |
Stroke volume |
11.2 ml |
Figure 2
Echocardiography. Four-chamber position: a) deep defects on the border of cacuminal and middle segments of interventricular septum and lateral wall in the basis of lateral papillary muscle. Diastole; b) systole.
|
Figure 2a Echocardiography. Four-chamber position: deep defects on the border of cacuminal and middle segments of interventricular septum and lateral wall in the basis of lateral papillary muscle. Diastole; |
Figure 2b Echocardiography. Four-chamber position: systole. |
|
|
Figure 3
Echocardiography. Two-chamber position. A deep defect on the border of cacuminal and middle segments of inferior wall of left ventricle.
Figure 4
Echocardiography. Small amount of fluid along posterior wall of left ventricle. Hemopericardium.
The identified changes showed a shear stress-associated endocardium rupture and myocardium bursting along lateral, inferior and lower septal region of LV. An unusual and surprising fact was preservation of contractile function of LV. The apical segments, which were more distal than the laceration region, contracted satisfactory. Possibly, there were not any significant injuries to coronary arteries. Despite of presence of a deep defect in the basis of the lateral papillary muscle, the function of the mitral valve was without changes.
The first blood analysis showed the leukocytosis (22.5*109/l, the reference - 6-10.7*109/l) and hyperenzymemia (the table 2). There were elevated levels of cardiac marker creatine phosphokinase MB fraction (292 U/l, reference – 0-24 U/l), lactic dehydrogenase (LDH) (1,181 U/l, reference – 0-300 U/l), aspartate aminotransferase (AAT) (490,7 U/l, reference – 0-48 U/l), alanine aminotransferase ALT (235.7 U/l, reference – 0-33 U/l).
Table 2
The dynamic changes in laboratory values of the patient C., age of 1 year and 9 months, for the treatment period
|
|
Date |
||||||||
|
Value |
At admission |
4th day |
5th day |
15th day |
20th day |
24th day |
40th day |
54th day |
Discharge day |
|
RBC, 1012
|
4.81 |
3.77 |
3.97 |
3.65 |
4.28 |
4.49 |
4.81 |
4.26 |
4.84 |
|
WBC, 109
|
22.5 |
12.05 |
13.47 |
10.1 |
9.03 |
9.35 |
8.8 |
7.6 |
6.8 |
|
Platelets, 109
|
182 |
260 |
295 |
456 |
336 |
369 |
228 |
298 |
326 |
|
Protein, g/l
|
62.5 |
51.3 |
59.6 |
61.6 |
71.7 |
70.6 |
70.3 |
68.2 |
70.2 |
|
ALT, U/l
|
235.7 |
126.7 |
87 |
16.5 |
14 |
12.6 |
12.6 |
12.8 |
12.1 |
|
ACT, U/l
|
490.7 |
33.6 |
27.8 |
24.4 |
28.2 |
25.9 |
32.7 |
32.6 |
38.1 |
|
LDH, U/l
|
1181 |
539 |
520 |
288 |
276 |
244 |
284 |
246 |
242 |
|
CPK-MB, U/l
|
292.8 |
18.7 |
33 |
13.7 |
15.9 |
15.6 |
15.2 |
19.2 |
18.6 |
The presence of cardiac injury was confirmed by high blood level of cardiomyocytolysis markers (the table 3). Troponin I level was 2.83 ng/ml in the first day (the reference – 0-16 ng/ml for age of 1-4). The high levels of NT-pro BNP were identified – 2,083 pg/ml (reference – 0-320 pg/ml for this age).
Table 3
Time course of troponin I and NT-proBNP for treatment period in the child, age of 1 year and 9 months
|
|
Date |
||||||||
|
Valye |
4th day |
5th day |
6th day |
12th day |
16th day |
20th day |
25th day |
31th day |
Discharge day |
|
Troponin I, ng/ml |
2.83 |
1.82 |
0.277 |
0.103 |
0.1 |
0.1 |
0.1 |
0.1 |
0.1 |
|
NT-proBNP, ng/ml
|
2083 |
2097 |
2183 |
2287 |
1630 |
1327 |
900 |
707.6 |
285 |
The diagnosis was made after the examination: “Polytrauma. Closed thoracic injury: blunt heart injury, circular incomplete laceration of left ventricle myocardium. Contusion of upper lobe of left lung. Blunt abdominal injury. Contusion and hematoma of hepatogastric ligament. Pancreatic gland contusion. Brain concussion. Scratches and bruises of left forearm, right leg and anterior surface of the chest”.
The child was in the intensive care unit. The severity of condition was determined by traumatic shock at the background of polytrauma, the severe thoracoabdominal injury, by characteristics and volume of the surgical intervention, the course of postsurgical period, respiratory failure at the background of postanesthesia depression. Infusion, antibacterial and hemostatic therapy, analgesia, inhalation of broncho- and mucolytics were conducted. Infusion of nitrates (Isoket) was conducted for decreasing pre- and postload to the left ventricle in the acute period.
Urgent live cardiologic consultation was conducted in the Kemerovo cardiologic center. The diagnosis was confirmed. Surgical treatment was not indicated. Nitrate infusion was continued in the acute period. Additionally, minimal dosages of ATE inhibitors were indicated.
The postsurgical period was without complications. The abdominal drain was removed on the 3d day. The sutures were removed on the day 9 and 10. The course of traumatic brain injury showed some positive trends.
Subsequently, the severity of the child’s condition was determined by the dominating heart injury, persistent high risk of LV myocardium rupture with possible hemorrhage to pericardium, and development of heart tamponade.
The time trends of ECG during hospital stay reminded the course of infarction in the inferior and lateral walls in adults. Gradually, ST segment elevation had been disappearing. Negative T wave appeared. The signs of electronegative tissue persisted in the inferior and apical lateral region of left ventricle (Fig. 5).
Figure 5
ECG one month after injury.
EchoCG showed the disappearance of hemopericardium signs on the 13th day. There were not any other trends. LVEF was within 70-75 %. The sizes of the chambers did not change.
The time course of troponin I level showed the highest values during a week, with normalization by the 6th day. NT Pro BNP was high on the 4th day (2,083 pg/ml, reference – 0-320 pg/ml). The highest level of this marker was on the 12th day (2,287 pg/ml). Then it started to decrease. By the moment of hospital discharge, this value decreased and normalized at the level of 285 pg/ml (the table 3). The level of leukocytes normalized on the 15th day (10.1*109/l), ALT – on the 15th day (16.5 U/l), AST – on the 4th day (33.6 U/l), CPK-MB – on the 4th day with subsequent slight elevation to 33 U/l on the 5th day and normalization on the 15th day (the table 2).
The objective examination did not show any extension of cardiac dullness during hospital period. Auscultation showed the muffled heart tones in the apex and short systolic noise along the left border of the sternum with the maximal value in the intercostals spaces 3-4 during the first month. One month after the injury, heart tones were loud, with correct rhythm and without noises. The sizes of the liver were highly enlarged during percussion within the first 20 days (the liver border protruded over 1.5 cm from the edge of costal arch) and normalized later. The spleen was not enlarged during the whole period of the follow-up. There was no edema.
There were not any disorders of rhythm and conduction over the whole period of the follow-up. It was confirmed by results of 24-hour monitoring of ECG.
Some remote consultations by cardiac surgeons from Meshalkin National Research Institute and Tomsk National Research Medical Center (Cardiology Research Institute) were made. A teleconference with Bakulev National Medical Research Center of Cardiovascular Surgery (Moscow) was conducted. The cardiac surgeons concluded the absence of indications for surgical intervention at that moment. For selection of further management techniques, they recommended cardiac MSCT with contrast media, and construction of 3D image of the heart.
Since rehabilitation for children with closed heart injury is almost absent at the present time, extension of mode of movements for the patient was determined on the basis of proper daily hemodynamic monitoring. The child stayed 27 days in the intensive care unit. Strict bed rest was adhered. The patient was transferred to the pediatric surgery unit on the day 28. He was in the individual room. His mother and the nurse cared for him. The bed rest continued for 1 month and 7 days from the injury moment. After that, the mode of movements was changed. The child was allowed to lie on his abdomen, to sit in the bed 5 minutes 3 times per day. The time of sitting and lying position on the abdomen had been increasing gradually. One and half month after the injury, the child was allowed to walk in the bed during 5 minutes, with subsequent increase in time. Gradually, it was allowed to take several steps in the room. Extension of movement mode was tolerated well. There were not any negative changes in hemodynamics.
On the day 62 after the injury, the child was transferred to the special pediatric cardiology unit of Barbarash Cardiology Center (Kemerovo) for realization of heart MSCT with contrast media. The diagnosis was confirmed during the examination. The child was discharged. His condition was satisfactory. Then, at the outpatient phase, the patient was observed by the pediatric cardiologist of the polyclinic.
Three months after the injury, the control follow-up showed that the child could move independently at home, could walk in the street; active games (fast running and jumps) were limited. ECG showed some signs of electronegative (scar) tissue in the inferior and apical-lateral region of the left ventricle. After hospital discharge, ECG was without significant changes (Fig. 6). The results of echocardiography did not find any changes. The previous picture persisted. Partial defects were in the inferior and lateral zones and in the basis of the papillary muscle (Fig. 7).
Figure 6
ECG 3 months after injury.
Figure 7
Echocardiography. Four-chamber position 3 months after injury.
This clinical case shows the unique case of severe cardiac injury with endocardium and myocardium laceration. The case also demonstrates the unique compensatory abilities of child’s body which preserve all cardiac functions in such severe injury.
During 25 years of experience in our clinic, we identified various manifestations of cardiac injury in patients with severe thoracic trauma. The most severe cases of heart contusion were accompanied by decrease in contractile ability of left ventricle, by dilatation of left cameras and disorder of local contractility of LV. The signs of hemopericardium were found in several cases. Hemodynamics suffered in all cases. Hypotonia, disorders of rhythm and conductivity were found. We did not deal with cases as the above mentioned one.
CONCLUSION
The follow-up and treatment in the special clinical center allowed rapid examination of the child with polytrauma, with identification of a severe cardiac injury. The management methods were developed with participation of the consultative specialists from four big cardiac surgery centers of the country. Appropriate daily control of all hemodynamic values, including all available additional studies along with clinical signs, allowed activation of the child with gradual increase in movements, without any complications.
This case cannot be considered as completed because it is difficult to suppose how the heart structure will change during process of its growing.
This case of heart injury is extremely rare. Its feature is preservation of all main cardiac functions in presence of deep incomplete myocardium laceration. We hope that this case will be useful for specialists dealing with the problem of thoracic trauma.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflict of interests relating to publication of this article.