Pediatric “Found Down” Trauma Diagnosis and Therapy for Associated Clinical Pictures Using the “STAND UP 4C” Approach

Abstract

Background: Although “found down” trauma patients are not subject to any general definition in Germany, the term describes a recurrent clinical picture in the care of adult patients, especially in pre-hospital emergency settings. It is characterized by immobilization-related morbidity due to rhabdomyolysis and electrolyte disturbance-related severe arrhythmias. The aim of this work is to identify cases of pediatric “found down” patients treated at our institution and to define diagnostic and therapeutic measures. Methods: In a retrospective, monocentric observational study, the hospital information system was searched for “found down”-associated diagnoses on admission to the pediatric intensive care unit (PICU) of the University of Oldenburg for the period 1 January 2011 to 31 December 2022. After viewing 17 patient records, an interdisciplinary consensus concerning the clinical picture of “found down” was identified in five patients, and these patients were analyzed. Results: The mean age of patients was 8.73 (0.17–17.35) years, and patients were at the PICU for an average of 18.2 (14–24) days. Prolonged immobilization (n = 1), acute trauma (n = 2), and acute (n = 1) and chronic (n = 1) neurometabolic disorders were identified as triggers. The survival rate was 100%. Numerous associated disease symptoms, such as central nervous deficits, were detected. Conclusions: There are various causes for the pediatric clinical picture of “found down” trauma patients. However, pediatric “found down” trauma describes a complex, life-threatening disease affecting multiple organ systems. The diversity of the underlying causes of the diseases represents a challenge for adequate management. The acronym “STAND UP 4C” aims to provide guidance for the diagnosis and therapy.

1. Introduction

In general, “found down” trauma is a post-event diagnosis which is described as a symptom complex resulting from muscular tissue damage due to localized reduced perfusion under reduced mobility or traumatic effects. Potential causes, such as immobilization of trauma (fall) or neurological origin (intracerebral hemorrhage, intoxication), have so far only been described in adult medicine, but are equally conceivable in pediatrics [1,2]. With regard to the relevant outcomes and correct allocation for pediatric patients, clear definitions and derived treatment strategies are considered essential for the prevailing regional medical systems [3]. The clinical picture is distinguished by a multi-layer symptom complex with potentially vital drastic pathologies. These can include disturbances in kidney function or cardiac arrhythmias. In adult medicine, the need for intensive medical care in affected cases is described as 69%, with an in-hospital mortality rate of up to 50% [1]. Due to the lack of generally accepted definitions, information on the incidence can only be provided to a limited extent. In 18% of the cases of rhabdomyolysis in children, a traumatic genesis in the sense of the above-mentioned pathomechanism could be described [4]. In addition to a traumatic cause, other potential causes and consequences of “found down” are associated with disorders that are generally recognized as reversible causes of cardiac arrest (e.g., hypovolemia, electrolyte disturbances, acid–base disorders, etc.). This once again illustrates the potentially lethal consequences of this clinical picture until the occurrence of out-of-hospital cardiac arrest (OHCA) [5,6]. To our knowledge, there is no scientific research on pediatric “found down” trauma. The intention is to take a closer look at this symptom complex. Based on the identified cases, possible clinical courses, complications and therapy options should be analyzed, in addition to accompanying pathologies, with the aim of raising awareness of its possible occurrence in pediatrics and to present a system for recording and treating the symptom complex.

2. Materials and Methods

Since a clear definition of “found down” does not exist in either adult medicine or pediatrics, a special procedure was used to record the symptom complex:

First an approximation using the research literature in text-based meta-databases (PubMed^®, Medline^®-National Library of Medicine, Bethesda, MD, USA) was selected for the identification of cases of pediatric “found down” trauma patients. Here, in retrospective examinations, clinical pictures and complications could be detected in adults that seem to be associated with the occurrence of long lie trauma or “found down” [1]. In the second step, detected symptom complexes and diagnoses were subjected to an ICD coding, so that on the basis of this, ICD classifications of traumatic anuria (T79.5), malignant cardiac arrhythmia (Z01.80), traumatic muscle ischemia (T79.6), and hypothermia (R68.0) could be defined as the inclusion criteria. On this basis, it was possible to search in the hospital’s own information system (Cerner KIS Medico^®, Berlin, Germany) for admission diagnoses at the pediatric intensive care unit (PICU) of the University of Oldenburg in the period from 1 January 2011 to 31 December 2022 with the ICD codes mentioned above. In total, 17 data records were detected this way; these were subjected to an examination by specialists (specialization in pediatrics and anesthesiology), independently of one another. Cases were included whose anamnestic information on the patient’s immobilization was consistently assessed by both specialist disciplines as a possible genesis of one of the above-mentioned clinical pictures associated with “found down” trauma patients. In the end, n = 5 cases of the 17 data records were included (Figure 1).

In addition to the patient master data for the cases in question, it was important that the associated laboratory parameters were recorded. Measurement values of body temperature (temp) refer to the initial measurement. A pathological gas exchange (paO₂ < 80 mmHg and/or SpO₂ < 95%) under room temperature air, a necessary O₂ administration, or morphologically respiratory pathologies were evaluated as a respiratory disorder. For the detection of neurological impairments, documented disorders of consciousness, sensory, or motor function have been analogously searched for. The assessment of laboratory parameters was performed after the determination of the case-related medians, as well as the 25% and 75% quartiles, with associated median, maximum, and minimum values. On the one hand, a cross-case overview of all laboratory parameters with the percentage of measurements outside the age-appropriate standard and, on the other hand, a case-related presentation of the corresponding laboratory parameters were selected.

3. Results

The average age of the exclusively male patients was 8.73 (min. 0.17–max. 17.35) years, with an average intensive medical length of stay of 18.2 (min. 14–max. 24) days. All patients were presented by the emergency rescue service and treated at the PICU. As trigger for “found down” trauma, immobilization after traumas (n = 3) or acute neurological and metabolic events (n = 2) were identified. While two cases of traumatically induced “found down” traumas were caused by an acute event, one case was caused by pre-existing chronically impaired motor function. For the two cases that were triggered by neurological and metabolic disturbances, it could not be determined finally whether an acute event or the exacerbation of an existing disturbance was the trigger. In the documentation of the pre-clinical treatment, the diagnosis of “found down” trauma was not mentioned, while a selection of the associated clinical pictures described above were mentioned as suspected diagnoses. The following associated disease symptoms were detected: central nervous deficits, rhabdomyolysis, metabolic derailments, hypothermia, hemodynamic, cardiac, and respiratory complications, primary and secondary associated infections and hemostasis disorders. On admission, four out of five patients showed hypothermia and 60% of the cohort showed neurological and/or respiratory disorders. In 80% of the cases, surgical interventions were undertaken. In three cases, these consisted of the surgical treatment of a compartment syndrome. The survival rate was 100%. With regard to the influence of the COVID-19 pandemic in the years 2020–2022 [7,8], which has been proven in other areas, the corresponding period in the present study showed no deviations in the number or severity of cases. Figure 2 shows the case-related measurement values determined in the median with averaging of the values for the entire cohort (cases 1–5). A total of 62.5% of the parameters collected (n = 10 of 16) showed deviations from the reference range of the age-appropriate standard.

An analysis of all measured values concerning the 14 laboratory parameters associated with “found down” trauma showed a high variability inside and outside the age-appropriate norm. In particular, the values measured in connection with muscular damage (creatine kinase and creatinine) showed significant increases (Figure 3).

4. Discussion

Given the multi-factor genesis of “found down” trauma and the resulting difficulty of securing a diagnosis, raising awareness of this clinical picture in the emergency and intensive medical treatment of pediatric patients is required [9]. The performance of a comprehensive diagnosis of the organ systems with derivation of the necessary therapeutic consequences is of great relevance for the success of the treatment [10].

In the course of the literature research undertaken, it was possible to show that cases of “found down” trauma, in addition to traumatic genesis or consequences such as compartment syndrome and rhabdomyolosis, can also accompany non-traumatic causes or effects. In the synopsis, potential functional disorders in almost all areas of the organ system—neurological, cardiopulmonary, renal, metabolic, and infectious—could be demonstrated [11]. As a consequence of the retrospective case analysis undertaken, the authors have developed the acronym STAND UP 4C for the treatment process of “found down” trauma. This should contribute to the optimization of detection and treatment of this symptom complex (Figure 4).

S Search for reasons

Three cases could be assigned to an acute event or neurological genesis, as a result of which immobility with perfusion deficits of the tissue or a direct traumatic effect caused the corresponding symptoms. In two cases, “found down” trauma was observed as a complication of a chronic condition. Here, disorders and diseases of the musculoskeletal system, with an immediate restriction of mobility, as well as underlying diseases with a neurological and/or metabolic genesis and secondary mobility restrictions represent further risk factors [9]. The differentiated picture of underlying causes and the temporal progression of occurrence that can be seen here reflects the evaluation of cases in adult patients. It could also be shown here that the detection of “found down” trauma cannot be achieved exclusively via a trauma that is in the foreground. The compilation of the affected patient client base is described with a nearly equal share of traumatic and non-traumatic disturbances, and interpreted as a high requirement for the triaging to be carried out. As almost 15% of cases in adults were found to be inadequately triaged, research into the causes is particularly important in suspected cases of “found down” trauma patients [12].

T Temperature

The discrepancy between the reduced ability to generate heat due to reduced muscle activity and lack of food intake and the increased level of heat release explains the connection between “found down” trauma patients and hypothermia [13]. The patients in this study had an average body temperature of 33.4 °C on admission. Pathophysiologically, an inhibition of glutamate synthesis is the consequence of hypothermia. This leads to a decrease in excitatory neurotransmitters in the CNS, with a consecutive reduction in nerve conduction velocity and weakened reflexes [14]. Hypothermia can, in addition to hemostaseological and metabolic disturbances, also cause hemodynamic instability. Although the pathophysiological correlations of this phenomenon, also known as “mountain death”, are not yet fully understood, isolation and immobilization in as horizontal a position as possible are recommended measures in the care of hypothermic patients [15]. For the treatment of hypothermia, there are various methods available, including passive, active external, and internal processes, with and without circulatory support [16]. Due to the danger of hemodynamic instability due to heat-induced peripheral vasodilation, suitable access to a secure dosage of hemodynamically effective medicines should be created before starting measures. A limitation of the rewarming rate (°C/h) in case of new or pre-existing cardiopulmonary instability can also be necessary [17].

A Anti-infectives

Depending on the clinical presentation, especially for patients with “found down” trauma, samples of material for microbiological diagnosis (swabs, aspirates, urine, blood culture, etc.) should be taken, if possible, before starting anti-infective therapy. According to the Tarragona strategy, an empirical anti-infective therapy should then be started quickly before the goal-oriented therapy can be adjusted after identification of the pathogens [10]. For the infection parameters leukocytes and CRP, more than 50% of the cases analyzed showed values above the age-appropriate norm. A raising of awareness of signs of inflammation potentially related to “found down” trauma therefore seems indispensable. In particular, a sepsis or necrotic fasciitis, as a complication of a compartment syndrome occurring in “found down” trauma patients, can represent additional threats to life.

N Neurology

In addition to a cerebrovascular genesis or intoxication, the reasons for impaired vigilance may be disorders of homeostasis in the fluid, volume, and electrolyte balance, as well as the consequences of hypothermia [12]. In the initial examination, consciousness should be checked and an examination of pupils, reflex status, as well as muscle tone and spontaneous muscle movement should be performed. In addition, there should be a search for signs of meningism, indications of a seizure event, or an increase in brain pressure [18]. In three out of five patients, neurological disturbances were recorded during examinations upon admission. In the course of extended diagnosis, in addition to imaging processes, laboratory chemical examinations should be performed to detect neurological, toxic, or hormonal genesis [19]. If indications are found, urgent measures such as the securing of breathing passages or the balancing out of metabolic disturbances should be undertaken without losing any time [20].

D Disturbances of electrolytes

Disturbances in electrolyte balance can contribute to the incidence of pediatric “found down” trauma, as well as represent consequences of accompanying symptoms. For therapy for electrolyte derailing in connection with rhabdomyolysis, the prompt reaching of a normokalemia should be primarily strived for. The emergency treatment of life-threatening hyperkalemias can be initiated through membrane stabilization with calcium (e.g., calcium gluconate 10% 0.5 mL/kgKG, max. 20 mL) or the redistribution of the calcium with quick-acting insulin with glucose (e.g., 0.1 U/kgKG insulin, mixing ratio 1 IE insulin in 25 mL glucose 20% solution). Furthermore, the high-dose nebulization of beta-agonists and the administration of sodium bicarbonate (e.g., 1 mmol/kg ECG i.v.) in the case of metabolic acidosis, and the application of furosemide in the case of adequate volume status should be considered. If there is still a risk to life, dialysis is another therapy option. In the absence of a bleeding tendency, mild hypocalcemia can be tolerated, and the use of phosphate binders at phosphate levels < 7 mg/dL can be dispensed with in favor of volume and diuretic therapy [4].

U Urine

Upon suspicion of a toxic genesis, the screening of urine is indicated. Components of an examination routine are, here, generally the detection of alcohol, benzodiazepine, opioids, barbiturates, as well as synthetic drugs [21]. A red coloration of the urine can be an indication of rhabdomyolysis [22]. The estimation of volume status using the quantity of urine, by contrast, has proven unreliable [23]. However, the pathomechanisms of acute renal failure due to rhabdomyolysis can be counteracted by controlling forced diuresis. The progression of initially existing hyperphosphatemia with the risk of organ calcification can also be reduced by diuresis-controlled therapy [4].

P Pulmo

Disorders of this organ system were detected in 60% of the values recorded for gas exchange, oxygen demand, or image morphology. An initial cold-associated hypersecretion can, accompanied by a reduced cough reflex due to reflex damping, cause secretion retention or aspiration. The subsequent disturbance of the mucociliary clearance can, as a result, facilitate the formation of atelectases and a reduction in the diffusion area and vital capacity. The resulting disproportion of ventilation and perfusion is also influenced by changed breathing mechanics. If compensatory mechanisms, such as increasing the breathing volume, are still effective at the beginning, respiratory exhaustion can occur with increasing duration. Inflammation-related permeability disturbances and accumulations of fluid contribute to an increase in the diffusion path. A hypothermia-induced leftwards shift in the oxygen-binding curve can promote the progression of hypoxia [24]. In addition to detecting disturbances of the respiratory system, it is possible to estimate, using the arterial blood gas parameters, the extent of respiratory insufficiency and an indication for non-invasive or invasive ventilation. Imaging procedures can provide further information (lung expansion, pleural effusion, ventilation disorders, etc.) regarding the indication of drainage or bronchoscopy [25].

C Cardiac Arrest

The risk of malignant cardiac arrhythmias exists, especially pre-clinically, due to an increased myocardial irritability. This arises due to changes in the membrane potential and changes in the ion homeostasis in cases of hypothermia. They can cause a cardiac arrest situation, which should be treated according to the guidelines [24,26]. The focus here is on raising awareness for a dynamic worsening of condition, as well as the monitoring of vital function with the continuous derivation of an EKG. There were no severe cardiac arrhythmias in any of the cases presented here.

C Creatine kinase (CK)

In addition to trauma consequences, toxins and metabolic disturbances are triggers of rhabdomyolysis [27]. Both traumatic damage to the myocytes through direct exposure to force (crushing, compression, etc.) and a disturbed ion homeostasis of the muscles due to an imbalance between energy demand and supply are discussed as leading mechanisms of rhabdomyolysis [28]. Because a standardized definition is lacking, CK values > 1.000 U/L or five times the norm in connection with myalgias, muscular weakness, or red coloration of the urine are regarded as a pathognomonic triad [22]. For the cases presented here, with a CK of 2485.3 U/L in the median, at least one of these criteria was met. In the further course of the disease, the CK serves as the laboratory chemical marker for diagnosis, progression, and therapy response. The dynamic progression is described with the highest value after approx. 3–5 days and a near-normalization after approx. 10 days [29]. Under laboratory controls and clinical assessment, a forced supply of crystalloid full electrolyte solutions, possibly with the use of loop diuretics, can be started according to the recommendations for weight-adapted target diuresis of 4–5 mL/kgKG/h [30]. Creatinine and urea, as laboratory chemical retention parameters, were increased in approx. two-thirds of the measurements in the cases presented. With quick therapy responses, additional measures such as urinary alkalization, the administration of mannitol, or dialysis were not necessary [31].

C Compartment

In the cohort examined, a compartment syndrome was surgically treated in three cases. The occurrence could be observed as arising in immediate relation to the traumatic genesis of the “found down” trauma and as a secondary complication. While microvascular impairment due to interstitial pressure increase in a fascial compartment is the pathophysiological basis for both adult and pediatric patients, there are differences in diagnosis and treatment [32]. In particular, the “5 Ps” (pain, paresthesias, paralysis, pallor, and pulseless) described in many cases when diagnosing adult patients appear to only be of limited use in pediatrics. In addition to ensuring normotension, freeing the extremities from materials that potentially restrict circulation and positioning at heart level, surgical decompression should be considered promptly [33]. In addition, the necrotizing fasciitis already mentioned must be regarded as a severe, life-threatening complication.

C Coagulation

There should be a differentiation between traumatic bleeding and coagulation disorder. In addition to conventional laboratory parameters such as Quick/INR, PTT, and fibrinogen, point of care coagulation diagnosis, with the application of viscoelastic procedures, represents another possibility for optimizing therapy [34]. In addition to the genesis of traumatic bleeding, existing rhabdomyolysis can lead to increased release of tissue thromboplastin with induced disseminated intravascular coagulation (DIC) [12]. Using the ISTH (International Society of Thrombosis and Hemostasis) DIC score, which is only validated to a limited extent for children, the indication for drug-induced anti-coagulation can be assessed and weighted against possible bleeding complications [35]. In two cases, the median PTT values were prolonged above the age-appropriate norm. When drug anti-coagulation was carried out, these findings were not evaluated as an expression of DIC.

5. Limitations

Due to lacking ICD classification, an approximation of the clinical picture described was only possible via retrospective evaluation with admission diagnoses associated with pediatric “found down” trauma. The design and the type of cases identified could have led to a selection bias. The data could be incomplete or there could be errors in inclusion and exclusion. No comparisons were made with a control group. In the course of this, only a small number of patients could be included. Therefore, general statements or conclusions about the overall population are only possible to a limited extent. Furthermore, no reliable statements can be made about the effects on the examined clinical picture during the COVID-19 pandemic. The reasons for this are limited case numbers with a consecutive lack of significance, as well as a lack of data collection, such as those examined in other studies due to extended waiting times until definitive medical care [36]. However, according to the current state of knowledge, the present study describes an initial approximation of this clinical picture and its therapy for pediatric patients.

6. Conclusions

Pediatric “found down” trauma confronts actors with the challenge of recording a clinical picture that rarely occurs in this age class and treating it adequately. In the future, a generally valid definition of the diagnosis is desirable, on the basis of which diagnostic and therapeutic measures should be taken. This could help to avoid missing an early transfer to a hospital with maximum pediatric intensive care in the event of initial suspicion. In the meantime, the use of acronyms can help to identify and close gaps in diagnosis and treatment in order to increase confidence in the care of these children [37]. STAND UP 4C was developed for the clinical picture described and adapted to a protocol-based procedure for corresponding suspected diagnoses.

In suspected cases of “found down”, potential triggers must be investigated using a variety of available diagnostic procedures. Neurological disorders can be narrowed down using physical and laboratory examinations or operative or imaging procedures such as EEG, CT, MRI, etc. The same applies to the investigation of a cardio/pulmonary genesis using echocardiography, hemodynamic monitoring, lung/sonography, X-ray, etc. In addition to the routine collection of retention parameters, a nephrological disorder can also be diagnosed by sonographic checks, urine balancing and examinations, or hemodynamic monitoring. Infectious causes are diagnosed as standard by collecting infection parameters and securing material. Finally, surgical intervention can represent a further component in the diagnosis and treatment of “found down” trauma.

Overall, in pediatric patients, it also appears appropriate, e.g., using STAND UP 4C, to check the presence of “found down” by means of diagnostic procedures in order to be able to take therapeutic measures if necessary. Examples of a practical approach to suspected pediatric “found down” trauma have now been integrated into the conclusion of our study. In addition, a brief overview of the diagnosis of organ-specific disorders is given.