Serum troponin-I as an indicator of clinically significant myocardial injury in paediatric trauma patients

Beyond the brain: General intensive care considerations in pediatric neurocritical care

Managing children with critical neurological conditions requires a comprehensive understanding of several principles of critical care. Providing a holistic approach that addresses not only the acute interactions between the brain and different organ systems, but also critical illness-associated complications and recovery is essential for improving outcomes in these patients. The brain reacts to an insult with autonomic responses designed to optimize cardiac output and perfusion, which can paradoxically be detrimental. Managing neuro-cardiac interactions therefore requires balancing adequate cerebral perfusion and minimizing complications. The need for intubation and airway protection in patients with acute encephalopathy should be individualized following careful risk/benefit deliberations. Ventilatory strategies can have profound impact on cerebral perfusion. Therefore, understanding neuro-pulmonary interactions is vital to optimize ventilation and oxygenation to support a healing brain. Gastrointestinal dysfunction is common and often complicates the care of patients with critical neurological conditions. Kidney function, along with fluid status and electrolyte derangements, should also be carefully managed in the acutely injured brain. While in the pediatric intensive care unit, prevention of critical illness-associated complications such as healthcare-associated infections and deep vein thrombosis is vital in improving outcomes. As the brain emerges from the acute injury, rehabilitation and management of delirium and paroxysmal sympathetic hyperactivity is paramount for optimal recovery. All these considerations provide a foundation for the care of pediatric patients with critical neurological conditions in the intensive care unit.

Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.

Risk factors and outcomes in pediatric blunt cardiac injuries

PURPOSE

Unlike adults, less is known of the etiology and risk factors for blunt cardiac injury (BCI) in children. Identifying risk factors for BCI in pediatric patients will allow for more specific screening practices following blunt trauma.

METHODS

A retrospective review was performed using the Trauma Quality Improvement Program (TQIP) database from 2017 to 2019. All patients ≤ 16 years injured following blunt trauma were included. Demographics, mechanism, associated injuries, injury severity, and outcomes were collected. Univariate and multivariate regression was used to determine specific risk factors for BCI.

RESULTS

Of 266,045 pediatric patients included in the analysis, the incidence of BCI was less than 0.2%. The all-cause mortality seen in patients with BCI was 26%. Motor-vehicle collisions (MVCs) were the most common mechanism, although no association with seatbelt use was seen in adolescents (p = 0.158). The strongest independent risk factors for BCI were pulmonary contusions (OR 15.4, p < 0.001) and hemothorax (OR 8.9, p < 0.001).

CONCLUSIONS

Following trauma, the presence of pulmonary contusions or hemothorax should trigger additional screening investigations specific for BCI in pediatric patients.

Cardiac-cerebral-renal associations in pediatric traumatic brain injury: Preliminary findings

OBJECTIVE

The clinical epidemiology of organ outcomes in pediatric traumatic brain injury (TBI) has not been examined. We describe associated markers of cerebral, cardiac and renal injury after pediatric TBI.

DESIGN

Prospective observational study.

PATIENTS

Children 0-18 years who were hospitalized with TBI.

MEASUREMENTS

Measures of myocardial (at least one elevated plasma troponin [cTnI] ≥ 0.4 ng/ml) and multiorgan (hemodynamic variables, cerebral perfusion, and renal) function were examined within the first ten days of hospital admission and within 24 h of each other.

MAIN RESULTS

Data from 28 children who were 11[IQR 10.3] years, male (64.3%), with isolated TBI (67.9%), injury severity score (ISS) 25[10], and admission Glasgow coma score (GCS) 11[9] were examined. Overall, 50% (14 children) had elevated cTnI, including those with isolated TBI (57.9%; 11/19), polytrauma (33.3%; 3/9), mild TBI (57.1% 8/14), and severe TBI (42.9%; 6/11). Elevated cTnI occurred within the first six days of admission and across all age groups, in both sexes, and regardless of TBI lesion type, GCS, and ISS. Age-adjusted admission tachycardia was associated with cTnI elevation (AUC 0.82; p < 0.001). Reduced urine output occurred more commonly in patients with isolated TBI (27.3% elevated cTnI vs. 0% normal cTnI).

CONCLUSIONS

Myocardial injury commonly occurs during the first six days after pediatric TBI irrespective of injury severity, age, sex, TBI lesion type, or polytrauma. Age-adjusted tachycardia may be a clinical indicator of myocardial injury, and elevated troponin may be associated with cardio-cerebro-renal dysfunction.

Interventricular Septal Pseudoaneurysm After Blunt Chest Trauma in a 6 Year Old: An Illustrative Case and Review

Motor vehicle accident is the most common cause of blunt cardiac injury (BCI) in children (85.3%) due to the height of the child in relation to proper restraints and the compliant pediatric rib cage (J Trauma. 1996;40:200-202). Trauma to the chest wall may lead to injury of the myocardium, resulting in myocardial contusion, ventricular septal defect (VSD), ventricular free wall rupture, or valve compromise (J Trauma. 1996;40; 200-202; Heart Lung. 2012;41:200-202; J Inj Violence Res. 2012;4:98-100). There are several proposed mechanisms for the formation of VSD after blunt chest trauma including rupture of ischemic myocardium related to the initial trauma and reopening of a spontaneously closed congenital VSD. Also, chest trauma during isovolumetric contraction of the ventricles may generate enough intraventricular force to cause myocardial rupture (J Trauma. 1996;40:200-202; J Inj Violence Res. 2012;4:98-100; Korean J Pediatr. 2011;54:86-89; Ann Thorac Surg. 2012;94:1714-1716; J Emerg Trauma Shock. 2012;5:184-187). Previous case reports highlight the formation of a true VSD after BCI and the requirement of emergent repair (J Emerg Trauma Shock. 2012;5:184-187; Am Heart J. 1996;131:1039-1041; Korean Circ J. 2011;41:625-628; Ann Thorac Surg 2013;96:297-298; Kardiol Pol. 2013;71:992; Chin Med J. 2013;126:1592-1593). Reported is a case of a 6-year-old girl who developed an interventricular septal pseudoaneurysm after a motor vehicle accident of pedestrian versus car. On the day of presentation, she developed bradycardia after emergent surgical repair for abdominal trauma that required cardiopulmonary resuscitation including 5 minutes of chest compressions. At the time of resuscitation, an emergent transthoracic echocardiogram noted an interventricular pseudoaneurysm. She has been followed with serial transthoracic echocardiograms and has not required surgical intervention. We discuss the risk factors, prevalence, and diagnostic studies and recommended treatment options for structural heart disease after BCI.

Brain injury biomarkers as outcome predictors in pediatric severe traumatic brain injury

BACKGROUND

To systematically review the literature on brain injury biomarkers, defined as any injury biomarker detected in cerebrospinal fluid (CSF) or blood injury biomarkers primarily expressed in the brain parenchyma, to determine outcome prediction in pediatric severe traumatic brain injury (sTBI).

METHODS

A search of MEDLINE(®), EMBASE(®), PsycINFO(®), Pubmed(®), and the Cochrane Database, as well as grey literature sources, personal contacts, hand searches, and reference lists. The search terms used were traumatic brain injury, biomarkers, prognosis, and children. No language, publication type, or publication date restrictions were imposed. All articles were critically reviewed by two clinicians independently.

RESULTS

A total of 7,150 articles were identified initially with 16 studies identified for review. Eighteen different biomarkers were examined; 11 in CSF and 7 in blood. Outcomes assessed included either in-hospital mortality or functional state (hospital discharge, 3-months or 6-months; Glasgow Outcome Scale or Pediatric Cerebral Performance Category). Significant correlations were established between sTBI outcomes and various biomarkers in CSF (IL-6, IL-8, IL-1β, S100β, NGF, NSE, DCX, ET-1, HMGB-1, cytochrome C) and blood (GFAP, NF-H, UCH-L1, SBDP-145, leptin). Mixed results were obtained for blood S100β. Outcome did not correlate with several biomarkers in either CSF (BDNF, GDNF, α-Syn) or blood (NSE, MBP). The Class of Evidence was considered II in 1 study and III in the remaining 15 studies.

CONCLUSIONS

Based on the status of current sTBI biomarker research, we recommend that future research should be directed at both novel biomarker discovery and validation of biomarker panels in large, well-designed longitudinal studies.

Blunt cardiac injury in critically ill trauma patients: a single centre experience

PURPOSE

This study describes the incidence and outcomes of blunt cardiac injury (BCI) in a single trauma intensive care unit (TICU), together with the spectrum of thoracic injuries and cardiac abnormalities seen in BCI.

METHODS

We performed a retrospective observational study of 169 patients with blunt thoracic trauma admitted from January 2010 to April 2013. BCI was diagnosed using an elevated serum troponin in the presence of either clinical, ECG or transthoracic echocardiography (TTE) abnormalities in keeping with BCI. The mechanism of injury, associated thoracic injuries and TTE findings in these patients are reported.

RESULTS

The incidence of BCI among patients with blunt thoracic trauma was 50% (n=84). BCI patients had higher injury severity scores (ISS) (median 37 [IQR 29-47]; p=0.001) and higher admission serum lactate levels (median 3.55 [IQR 2.4-6.2], p=0.008). In patients with BCI, the median serum TnI level was 2823ng/L (IQR 1353-6833), with the highest measurement of 64950ng/L. TTEs were performed on 38 (45%) patients with BCI, of whom 30 (79%) had abnormalities. Patients with BCI had a higher mortality (32% vs. 16%; p=0.028) and trended towards a longer length of stay (17.0 days [standard deviation (SD) 13.5] vs. 13.6 days [SD 12.0]; p=0.084).

CONCLUSIONS

BCI was associated with an increased mortality and a trend towards a longer length of stay in this study. It is a clinically relevant diagnosis which requires a high index of suspicion. Screening of high risk patients with significant blunt thoracic trauma for BCI with serum troponins should be routine practise. Patients diagnosed with BCI should undergo more advanced imaging such as TTE or TOE to exclude significant cardiac structural injury.

Bedside biomarkers in pediatric cardio renal injuries in emergency

Point of care testing (POCT) using biomarkers in the emergency department reduces turnaround time for clinical decision making. An ideal biomarker should be accurate, reliable and easy to measure with a standard assay, non-invasive, sensitive and specific with defined cutoff values. Conventional biomarkers for renal injuries include rise in serum creatinine and fluid overload. Recently, neutrophil gelatinase associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), cystatin C, interleukin-18 (IL-18) and liver fatty acid binding protein (L-FABP) have been studied extensively for their role in acute kidney injury associated with various clinical entities. Biochemical markers of ischaemic cardiac damage commonly used are plasma creatine kinase and cardiac troponins (cTn). Clinically valuable cardiac markers for myocardial injury in research at present comprise BNP/NT-proBNP and to a lesser extent, CRP, which are independent predictors of adverse events including death and heart failure. Current status of point of care biomarkers for diagnosis and prognostication of renal and cardiac injuries in pediatric emergency care is appraised in this review.