Heike Jakob

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort

Background:Although the incidence of pediatric patients in emergency services is as low as 5–10%, trauma remains one of the leading causes of death during childhood. Only a few reports exist about the quality of the initial treatment of pediatric trauma patients. Therefore, we tested the hypothesis of whether prehospital treatment and emergency management in pediatric trauma patients is similar to the treatment that is provided for adult patients.Materials and Methods:We performed a retrospective data analysis of the German Trauma Registry of the DGU from January 1993 to December 2007. Exclusion criteria were missing information about injury severity and/or age and patients older than 50 years. All pediatric patients were subdivided into five groups (infants 0–1 year, toddlers 2–5 years, children 6–9 years, pupils 10–13 years, teenagers 14–17 years) with regard to their age and were compared with the adult cohort (18–50 years). From 24,396 patients, 2,961 were below 18 years of age, thus, about 12% of the whole population of injured patients below the age of 50 years.Results:66.4% of infants sustained relevant head injuries (Abbreviated Injury Scale [AIS] ≥3), and this rate declined with increasing age. The mean Injury Severity Score (ISS) increased from 21.0 (±11.6) in the group of infants to 26.7 (±13.9) in the adult cohort. In all groups, the majority of patients were male. The injury pattern differed according to age, with predominant traumatic brain injury (TBI) in infants. During the preclinical treatment, infants were less often intubated and this was contrasted by a higher rate of cardiopulmonary resuscitation in this group (infants 16.2%, toddlers 6.8%, adults 3.1%). Diagnostic multislice computed tomography (CT) examination was less often performed in infants as compared to the other groups (infants 57.1%, toddlers 77.2%, adults 77.8%). Mortality and quality indicators such as timelines show no significant differences between children and adults.Conclusion:We observed typical age-dependent differences regarding the injury pattern and severity and differences referring to the preclinical and initial treatment. With respect to the high rate of serious TBI in the infants and toddlers age groups, a more focused education and training of emergency physicians and paramedics should be considered.

Effects of acute ethanol gavage on intestinal integrity after hemorrhage/resuscitation

Abstract Background. In hemorrhagic shock with subsequent resuscitation (H/R), increased pro-inflammatory changes contribute to tissue injury and mortality in rodent models. Ethanol (EtOH) is assumed to modulate the inflammatory response and the subsequent organ injury after H/R. Therefore, we determined the contribution of acute ethanol gavage on intestinal inflammation and injury as well as survival after H/R in rats. Methods. Fourteen hours before H/R, female LEWIS rats were gavaged with single dose of EtOH or saline (5 g/kg, 30% EtOH, H/R_EtOH group or H/R_ctrl group). Then, rats were hemorrhaged to a mean arterial blood pressure of 30 ± 2 mmHg for 60 min and resuscitated. Control groups underwent surgical procedures and gavage without H/R (sham_ctrl group and sham_EtOH group). Tissue was harvested 2 h after resuscitation. Mortality was assessed 72 h after H/R. Results. Ethanol gavage increased survival after H/R from 20% to 80%, but amplified plasma alanineaminotransferase (ALT) release compared to saline gavage (2847 ± 406 vs. 1159 ± 200 IU/L, p < 0.05). Intestinal mucosal damage index, intestinal permeability, ileal myeloperoxidase levels as indicators of polymorphonuclear leukocyte (PMNL) infiltration and systemic IL-6 levels as well as ileal IL-6 and TNF gene expressions after H/R were reduced and partly restored after ethanol gavage when compared to the saline gavaged group after H/R. Conclusions. Taken together, we propose that acute ethanol gavage prior to H/R 1) did not enhance intestinal mucosa injury after H/R and 2) suppressed the H/R-induced inflammatory response. Both findings seem to contribute to the ethanol-induced survival benefit after H/R in our model.

Das Polytrauma im Kindesalter

ZusammenfassungDie Behandlung schwerverletzter Kinder erfordert Kenntnis der möglichen Verletzungsursachen, Verletzungsmuster, Verletzungenshäufigkeit sowie der Mortalität. Je jünger die Kinder sind, desto deutlicher treten Unterschiede im Verletzungsmuster sowie in der Verletzungsschwere der betroffenen Organsysteme im Vergleich zum Erwachsenen auf. Prognostisch entscheidend sind beim Kind in erster Line Schädel-Hirn-Verletzungen und Thoraxtraumen. Abdominaltraumen können beim Kind deutlich häufiger als beim Erwachsenen konservativ therapiert werden. Auch Verletzungen des Körperstammskeletts und der Extremitäten erfordern ein altersadaptiertes operatives Vorgehen. Der vorliegende Beitrag geht sowohl auf die Primärdiagnostik im Rahmen der Schockraumversorgung als auch auf die spezifischen Behandlungsstrategien der einzelnen Organsysteme in Abhängigkeit von den anatomischen Besonderheiten beim Kind ein.AbstractImportant prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

Polytrauma im Kindesalter

ZusammenfassungDie Versorgung des Polytraumas im Kindesalter stellt für alle beteiligten Fachdisziplinen eine große Herausforderung dar, da auch in Kindertraumazentren nur etwa 10 bis 15 polytraumatisierte Kinder pro Jahr behandelt werden. Verletzungen, die infolge eines Unfalls entstehen, stellen die häufigste Todesursache im Kindesalter dar und können zu teuren lebenslangen Folgeschäden führen. Die Behandlungsstrategien unterscheiden sich teilweise erheblich von denen bei Erwachsenen, wobei anatomische und pathophysiologische Unterschiede sowohl Operations- als auch Nachbehandlungsverfahren beeinflussen. Umso wichtiger sind das kontinuierliche Training und die Zusammenarbeit des Behandlungsteams, um die Verletzungsschwere suffizient zu beurteilen und die adäquaten, altersadaptierten Therapiemaßnahmen einzuleiten. Da das Polytrauma des Kindes eine vergleichbar günstigere Prognose als dasjenige im Erwachsenenalter hat, muss das Primärziel der Behandlung schwerverletzter Kinder die möglichst vollständige Wiederherstellung unter Ausschöpfung aller erforderlichen diagnostischen und therapeutischen Maßnahmen sein.AbstractTreatment of polytraumatized children poses a challenge for all participating physicians, especially because even in pediatric trauma centers only 10–15 severely injured children are treated annually. Pediatric trauma is the number one cause of death in children, exceeding all other causes of death combined. Treatment strategies are different from adult polytraumatized patients. Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population. Therefore, continuous training and the cooperation of the treatment team is pivotal to evaluate the severity of the injury and initiate appropriate, age-adapted therapeutic measures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

Thrombin-activatable fibrinolysis inhibitor (TAFI) is enhanced in major trauma patients without infectious complications

BACKGROUND Infectious complications frequently occur after major trauma, leading to increased morbidity and mortality. Thrombin-activatable fibrinolysis inhibitor (TAFI), a procarboxypeptidase in plasma, plays a dual role in regulating both coagulation and inflammation. Activated TAFI (TAFIa) has broad anti-inflammatory properties due to its inactivation of active inflammatory mediators (anaphylatoxins C3a and C5a, bradykinin, osteopontin). OBJECTIVES The purpose of this study was to determine if TAFI plays a role in the development of inflammatory complications after major trauma. PATIENTS/METHODS Upon arrival at the emergency department (ED), plasma levels of TAFI and TAFIa were measured in 26 multiple traumatized patients for 10 consecutive days. Systemic levels of inflammatory mediators, including interleukin-6 (IL-6), procalcitonin (PCT), C-reactive protein (CRP) and leukocytes were determined. RESULTS Fifteen patients developed pneumonia and/or sepsis (compl) and 11 had no complications (wo compl). Overall injury severity and age were comparable in both groups. Complications occurred approximately 5 days after trauma. IL-6 increased on day 5, whereas CRP, PCT and leukocytes started to increase on day 6 in the compl-group. Upon arrival at the ED and on days 1 and 4, TAFI levels were significantly lower in the compl-group compared to the wo compl-group (p=0.0215). Similarly, TAFIa was significantly lower on day 4 in the compl-group than in the wo compl-group (p=0.049). CONCLUSIONS This pilot study shows that TAFI levels are inversely correlated with inflammation-associated development of complications after major trauma.

Delayed wound repair in sepsis is associated with reduced local pro-inflammatory cytokine expression.

Sepsis is one of the main causes for morbidity and mortality in hospitalized patients. Moreover, sepsis associated complications involving impaired wound healing are common. Septic patients often require surgical interventions that in-turn may lead to further complications caused by impaired wound healing. We established a mouse model to the study delayed wound healing during sepsis distant to the septic focus point. For this reason cecal ligation and puncture (CLP) was combined with the creation of a superficial wound on the mouse ear. Control animals received the same procedure without CPL. Epithelialization was measured every second day by direct microscopic visualization up to complete closure of the wound. As interplay of TNF-α, TGF-β, matrix metalloproteinases (MMP), and tissue inhibitors of metalloproteinases (TIMP) is important in wound healing in general, TNF-α, TGF-β, MMP7, and TIMP1 were assessed immunohistochemical in samples of wounded ears harvested on days 2, 6, 10 and 16 after wounding. After induction of sepsis, animals showed a significant delay in wound epithelialization from day 2 to 12 compared to control animals. Complete wound healing was attained after mean 12.2± standard deviation (SD) 3.0 days in septic animals compared to 8.7± SD 1.7 days in the control group. Septic animals showed a significant reduction in local pro-inflammatory cytokine level of TNF-α on day 2 and day 6 as well as a reduced expression of TGF-β on day 2 in wounds. A significant lower expression of MMP7 as well as TIMP1 was also observed on day 2 after wounding. The induction of sepsis impairs wound healing distant to the septic focus point. We could demonstrate that expression of important cytokines for wound repair is deregulated after induction of sepsis. Thus restoring normal cytokine response locally in wounds could be a good strategy to enhance wound repair in sepsis.

Time dependency and topography of hepatic nuclear factor κB activation after hemorrhagic shock and resuscitation in mice.

The leading causes of death in people aged 1 to 44 years are unintentional injuries with associated hemorrhagic shock. Hemorrhagic shock followed by resuscitation (H/R) activates the nuclear factor &kgr;B (NF-&kgr;B) pathway. To further address the association between liver damage and NF-&kgr;B activation, we analyzed the H/R-induced activation of NF-&kgr;B using cis-NF-&kgr;Begfp reporter gene mice. In these mice, the expression of green fluorescent protein (GFP) is linked to the activation of NF-&kgr;B, and therefore tracing of GFP colocalizes NF-&kgr;B activation. Mice were hemorrhaged to a mean arterial blood pressure of 30mmHg for 90 min, followed by resuscitation. Six, 14, or 24 h after resuscitation, mice were killed. Compared with sham-operated mice, H/R led to a profound hepatic and cellular damage as measured by aspartate aminotransferase, creatine kinase, and lactate dehydrogenase levels, which was accompanied by an elevation in interleukin 6 levels and hepatic leukocyte infiltration. Interleukin 10 levels in plasma were elevated 6 h after H/R. Using serial liver sections, we found an association between necrotic areas, oxidative stress, and enhanced GFP–positive cells. Furthermore, enhanced GFP–positive cells surrounded areas of necrotic liver tissue, predominantly in a penumbra-like–shape pericentrally. These results elucidate spatial relationship between oxidative stress, liver necrosis, and NF-&kgr;B activation, using an in vivo approach and therefore might help to further analyze mechanisms of NF-&kgr;B activation after resuscitated blood loss. ABBREVIATIONS ALT—alanine transaminase eGFP—enhanced green fluorescent protein H/R—hemorrhagic shock and reperfusion KC—Kupffer cells NF-&kgr;B—nuclear factor &kgr;B light-chain enhancer of activated B cells TLR—Toll-like receptor

Multiple trauma in pediatric patients

ZusammenfassungDie Behandlung schwerverletzter Kinder erfordert Kenntnis der möglichen Verletzungsursachen, Verletzungsmuster, Verletzungenshäufigkeit sowie der Mortalität. Je jünger die Kinder sind, desto deutlicher treten Unterschiede im Verletzungsmuster sowie in der Verletzungsschwere der betroffenen Organsysteme im Vergleich zum Erwachsenen auf. Prognostisch entscheidend sind beim Kind in erster Line Schädel-Hirn-Verletzungen und Thoraxtraumen. Abdominaltraumen können beim Kind deutlich häufiger als beim Erwachsenen konservativ therapiert werden. Auch Verletzungen des Körperstammskeletts und der Extremitäten erfordern ein altersadaptiertes operatives Vorgehen. Der vorliegende Beitrag geht sowohl auf die Primärdiagnostik im Rahmen der Schockraumversorgung als auch auf die spezifischen Behandlungsstrategien der einzelnen Organsysteme in Abhängigkeit von den anatomischen Besonderheiten beim Kind ein.AbstractImportant prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

Epidemiology and Management of Injuries to the Spinal Cord and Column in Pediatric Multiple-Trauma Patients

Injuries to the spinal column and cord in children are a rare condition. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of children with spinal injuries who were admitted to the emergency room. The patients were analyzed regarding age, mechanism, and distribution of their injuries to all spinal regions and treatment strategies. Thirty-five children met the inclusion criteria with severe spinal injuries (Abbreviated Injury Scale [AIS] for Region 6 [spine]; AIS region 6) in a period from January 2003 to December 2009. The incidence was extremely low in younger children, with increasing numbers during adolescence. Neurological deficit without fracture accounted for almost 25% of all patients. The majority of patients were treated conservatively; operative treatment was performed in 25% of patients with unstable fractures, particularly in adolescents. Treatment strategies differ according to the type and degree of injury, age, and level of spine maturation.