Mayo, Erin RN, MSN, CPNP-AC; Hackworth, Jodi MPH, CSTR; Billmire, Deborah MD, FACS
Department of Trauma Services, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana (Ms. Mayo and Hackworth and Dr Billmire); and Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana (Dr Billmire).
Correspondence: Erin Mayo, RN, MSN, CPNP-AC, Department of Trauma Services, Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Dr, Ste 1960, Indianapolis, IN 46202 (firstname.lastname@example.org).
The authors declare no conflicts of interest.
Trauma remains the leading cause of death in children.1 Blunt aortic injury is rare in the pediatric population, and most reports of pediatric blunt aortic trauma focus solely on the aortic injury.2–4 We present a case of blunt aortic dissection combined with multiple confounding traumatic injuries that was successfully managed with staged intervention.
A 54.2-kg, 14-year-old girl was involved in a motor vehicle crash as a restrained back seat passenger. The vehicle lost control on a patch of ice, and the passenger side of the car collided with a telephone pole. The patient's compartment directly sustained the majority of the impact. Upon arrival of emergency medical services to the scene, her Glasgow Coma Scale score was 3 and she was intubated and flown directly to the emergency department of our level 1 pediatric trauma center.
Upon arrival to the emergency department, initial vital signs were significant for marked hypotension, with blood pressure of 50/40 mm Hg and Glasgow Coma Scale score of 3. She rapidly received 2.5 L of crystalloid fluid and 500 mL of packed red blood cells, with improvement in blood pressure. Initial chest radiograph (Figure 1) revealed right lung base opacity, mildly displaced right clavicular fracture, and widening of the upper mediastinum. A triple-lumen central venous catheter was emergently placed in the right subclavian vein, and she was transported to the radiology department. Computed tomographic scans of the head, maxillofacial, chest, abdomen, and pelvis demonstrated extensive polysystem injuries (Table 1). Computed tomographic scan of the chest was significant for two contained descending aortic arch transections/pseudoaneurysms (levels T4-5 and T8) with hemomediastinum and pulmonary contusion (Figure 2). Head and maxillofacial computed tomographic scans were significant for a 1.5-cm epidural hematoma, skull base fractures, and complex facial fractures, as listed (Figure 3). Computed tomographic scan of the abdomen was significant for a grade 4 liver laceration. She was transported to the pediatric intensive care unit under the care of the pediatric surgery trauma service with consultations from the neurosurgery, cardiothoracic surgery, and pediatric intensivist services. An intracranial pressure (ICP) monitor and an arterial catheter were placed, and a management strategy was planned. Echocardiogram confirmed the aortic dissections and also revealed moderate mitral regurgitation with concern for possible ruptured chordal structure.
Management of the aortic injury required tight control of systolic blood pressure at less than 120 mm Hg to avoid rupture of the aortic pseudoaneurysms. This was achieved with an esmolol infusion that needed frequent titration. Management of the brain injury required strict control of ICP with attention to blood pressure, volume status, and ventilator strategy to optimize cerebral perfusion pressure (CPP) and oxygenation. The development of diabetes insipidus complicated the fluid management, and need for sedation also impacted both ICP and systemic blood pressure management. Pulmonary contusions, capillary leak, and progressive left pleural effusion required frequent shifts in ventilation strategy and left chest tube placement on postinjury day 4. Nitric oxide was eventually added to aid in oxygenation.
Magnetic resonance imaging/magnetic resonance angiography of the brain was obtained on day 1 to aid in assessing neurologic prognosis, as clinical examination was impeded by sedation and chemical paralysis. There was evidence of cortical and subcortical infarcts in a watershed distribution consistent with ischemic etiology, as well as partial thrombosis of the right sigmoid sinus and contusion of the anterior left temporal lobe with ischemic changes of the right hippocampus.
At 8 days postinjury, her overall clinical course, including ICP, had stabilized. The ICP monitor was removed, the paralysis was discontinued, and slow weaning of sedation was initiated. A nasojejunal tube was placed to allow addition of metoprolol for longer acting β-blocker therapy, and systolic blood pressure limit was raised to 140 mm Hg. Nicardipine was also added for blood pressure control. Sequential addition of a clonidine patch and amlodipine was also needed to achieve consistent blood pressures in the target range. Sedation weaning required addition of a temporary period of propofol, as enteral ativan and methadone were initiated. Pulmonary status gradually improved with weaning of the ventilator to lower settings. She had spontaneous eye opening and limited responsiveness to pain in all extremities.
On day 21, she underwent repair of her aortic injuries on full cardiopulmonary bypass with deep hypothermic circulatory arrest. The descending aorta was replaced with an 18-mm Gelweave graft. Intraoperative echocardiogram showed severe mitral regurgitation but normal leaflets and no signs of chordal rupture or prolapse. It was felt that this was most likely a congenital problem and no intervention was done for the mitral valve at the time of this operation.
All her organ systems gradually improved, and she was successfully extubated to room air on day 32. She had open reduction and internal fixation of the LeFort II fractures, open repair of the orbital blowout fracture, and placement of a gastrostomy on postinjury day 36. She was transferred to the rehabilitation service on day 43, with intensive daily physical, speech, and occupational therapies. She was discharged to home 73 days postinjury on room air and tolerating all diet by mouth. At last follow-up, oral intake had improved to the extent of no longer requiring supplementation through the gastrostomy button. Her gross motor coordination had also improved with ability to walk independently, and she had only some high-level balance difficulties and residual diminished function of her right hand. Echocardiogram demonstrates mild prolapse of the mitral valve with moderate regurgitation with normal left heart chamber sizes and function, as well as normal color Doppler findings in the descending aorta.
Trauma is the leading cause of death in children. Mortality is dependent on the severity of injury and multisystem involvement, with head injury as the most common direct cause of death. On the basis of the injuries in this patient, the Injury Severity Score5 was 66. The probability of survival based on physiologic measures, using the Revised Trauma Score6 and Injury Severity Score, was 2.1%. Treatment at a dedicated level 1 pediatric trauma center with multiple resources and coordinated care resulted in a successful outcome.
Blunt aortic injury is rare in the pediatric population and is primarily associated with motor vehicle crashes.7,8 Ejection and lateral impact collisions are associated with an increased risk of injury to the thoracic aorta.8 A study from the National Trauma Database reported an incidence of blunt thoracic aortic injury in children of 0.1%.4 Most patients with blunt aortic injury do not survive to reach care in the hospital setting and are dead at the scene approximately 85% of the time.8 In some cases, delayed operative repair has been shown to reduce overall mortality.9,10 Alternatively, endovascular stenting of traumatic aortic injuries in adults is used with increasing frequency.11–13 Early stenting was considered for this patient as a potential option, as this has also been reported successful in some limited cases of traumatic aortic injuries in the adolescent population.14 This ultimately was ruled out in this case, given the presence of 2 distinct and well-separated dissections, as well as concern for total lifetime radiation exposure in a young person who would require regular and long-term computed tomographic imaging follow-up of the endograft itself.
In this case, immediate discussion by all involved specialties considering the aforementioned options resulted in a strategy of delayed operative management for the aortic injury. As anticoagulation and cardiopulmonary bypass with deep hypothermic circulatory arrest would have been needed, the risk of bleeding from associated injuries and further compromise of the brain injury was felt to be excessive. The delay in operative repair would allow for correction of physiologic derangements, focus on early control of CPP and oxygenation, and reduce risk of bleeding as the associated injuries stabilized.
The management was particularly challenging because of the conflicting needs of optimal management for the head and aortic injuries. Evidential support for management of traumatic brain injury in the pediatric population has been well reviewed and summarized in the most recent second-edition update published in Pediatric Critical Care Medicine.15 Despite a lack of validated conclusive evidence in the guidelines regarding the acceptable goal range for CPP, there remains a reasonable clinical practice goal of maintaining CPP in the range of 40 to 50 mm Hg.15 This is accomplished with a combination of fluid resuscitation and adjunct vasopressor support. Vasopressors act by increasing vascular tone and therefore also systemic blood pressure. While increased systemic pressure is beneficial to the brain, vasopressors are entirely counter to the strategy required for medical management of aortic dissection. With aortic injury, avoidance of systemic hypertension is critical to avoid free rupture of the injured aorta. The goal in adult patients with aortic injury is for tight systolic blood pressure control in a range of 100 to 120 mm Hg.16 Pediatric recommendations are lacking, but the patient's age and size made use of adult standards reasonable. In the acute phase of early blood pressure control, esmolol proved to be the ideal continuous infusion choice because of its relatively short half-life and ability to be titrated quickly and easily in a constantly evolving setting of tenuous hemodynamics. The use of continuous sedation infusions to blunt the response to pain and noxious stimuli is accepted practice in avoiding sustained elevation of ICP following traumatic brain injury. In addition, paralytic infusion was also required for ICP management. Both of these strategies also impacted blood pressure control. The development of diabetes insipidus and fluid shifts related to capillary leak also impacted on volume status and blood pressure management. Ventilator management of the pulmonary contusion and acute respiratory distress syndrome required escalating positive end-expiratory pressure, which also impacted hemodynamic status.
Once the acute dynamic phase of injury had improved, transition to longer acting agents for blood pressure control and sedation could be initiated using enteral medications. Uncertainty regarding neurologic prognosis was also considered in timing for aortic repair. Sedation was weaned to assess responsiveness. As expected, weaning of the fentanyl and versed infusions resulted in increased need for β-blockade and a broadened antihypertensive regimen to maintain proper systolic blood pressure control. The maximum tolerance for systolic blood pressure was increased to 140 mm Hg, but blood pressure and agitation were difficult to control during this period. A short-term infusion of propofol was helpful in successfully managing the transition period because of its short half-life and dose-related hypotension properties. The risk of propofol infusion syndrome made this only a short-term solution.15
Many pediatric intensive care units are adopting a model of specialty intensive care patient populations. This patient benefited from receiving care in a unit where nurses maintain an expert knowledge in the care of patients with a broad range of complex problems. Our pediatric intensive care unit is a 35-bed multispecialty unit with nurses who have extensive experience and training in the care of patients suffering from polysystem trauma and neurosurgical conditions, patients having undergone cardiac surgery, and critically ill children with multiple organ system dysfunction. They were well prepared to understand and manage a patient with complex conflicting injuries, requiring a dynamic approach and frequently evolving care plan. The resources of a level 1 pediatric trauma center with rapid response and full access to all surgical and medical specialists were also important in planning and treating this child.
This case presented a rare challenge in the management of a child with contained aortic dissection along with severe traumatic brain injury and additional multisystem trauma. The conflicting needs of volume status, blood pressure control, and risk of hemorrhage required a dynamic and intensive plan of care. Despite a predicted mortality risk of 98%, she had a successful outcome with staged management of her multiple injuries in a level 1 pediatric trauma center with multidisciplinary nursing and surgical care.
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Blunt trauma; Traumatic aortic injury; Traumatic brain injury
Copyright © 2014 by the Society of Trauma Nurses.