The Prognostic Value of Troponin in Pediatric Polytrauma

Abstract

Introduction: Severe trauma accounts for a great number of deaths among children and adolescents. The diagnostic value of troponin serum levels of severely injured patients has been reported for adults, but data on pediatric polytrauma (PT) are scarce. Therefore, we conducted a retrospective monocentered study analyzing the prognostic value of troponin T (TnT) in pediatric trauma patients at the time point of hospital admission. Methods: Data of 88 polytraumatized pediatric patients admitted to the emergency room of the University Hospital of Ulm, Germany, between 2007 and 2016 were analyzed retrospectively. The data source was the written and digital patient records. Interleukin-6 (IL-6), creatine kinase activity (CK activity), and lactate and TnT levels were measured by a certified clinical diagnostic laboratory; and patients were stratified for the Injury Severity Score (ISS). The prognostic value for lung contusion, organ dysfunction, and fatal outcome was statistically explored. The study was approved by the independent ethical committee of the University of Ulm (#44/18). Results: TnT levels were significantly increased in patients after severe PT compared with mild or moderate trauma severity as assessed by ISS values. Patients with TnT levels above the cutoff showed significantly increased levels of IL-6 and CK activity and a significantly prolonged stay in the intensive care unit. However, TnT levels did not correlate with absolute ISS values. TnT levels were significantly increased in patients with chest trauma and lung contusion. The incidence of lung contusion was associated with elevation of TnT. So was the onset of organ dysfunction, defined as a Sequential Organ Failure Assessment (SOFA) score ≥ 2 and fatal outcome, with a significant enhancement of plasma levels in children with organ dysfunction and in non-survivors. Conclusion: These descriptive data suggest that evaluation of TnT on admission of multiply injured children may help in predicting severity of injury and mortality in the clinical course after trauma and thus may be a useful addition to established prognostic parameters in the future.

Keywords: cardiomyopathy; emergency room; lung contusion; polytrauma; thorax trauma; troponin.

Figure 1

Descriptive epidemiological data of the included cases. (A) Number of cases for each type of accident, sorted by age groups. The most frequent type of accident in all age groups but infants were road traffic-associated accidents. Falls from height < 3 m, sporting accidents, animal attacks, and so were put together as “miscellaneous.” (B) Number of cases for each Injury Severity Score (ISS) group sorted by age. In all groups, there was an approximately parametric distribution of cases. At higher age, a weak association with higher ISS values was observable. (C) Number of cases for each ISS group sorted by a type of accidents. No distinct pattern as to which type was associated with more severe trauma could be detected. ISS-A, ISS group A (included range: 0–16; n = 18); ISS-B, ISS group B (included range: 16–24; n = 37); ISS-C, ISS group C (included range: 25–32; n = 18); ISS-D, ISS group D (included range: >32; n = 15).

Figure 2

Cases were stratified into two groups, those with plasma TnT levels below (TnT–) and above (TnT+) a set cutoff of 14 ng/ml. (A) Injury Severity Score (ISS) values did not significantly differ between groups. (B) Interleukin 6 (IL-6) and (C) creatine kinase activity (CK activity) levels were significantly increased in the TnT+ group. (D) Further, the TnT+ group presented with a significant increase of the median length of stay in the intensive care unit (ICU). Data depict median and quartiles. In (B), two data points (IL-6; subject 52: >5,000 pg/ml; subject 61: 709 pg/ml) in the TnT+ group are not shown for better visualization. In (C), one data point (CK activity; subject 52: 5,881 U/L) in the TnT+ group is not shown for better visualization. TnT, troponin T.

Figure 3

Troponin T (TnT) levels were compared for various cohorts. Patients with (A) thorax trauma and (B) lung contusions showed significantly increased levels of TnT. (C) Also, in the cohort with organ dysfunction as defined by a Sequential Organ Failure Assessment (SOFA) score ≥ 2, TnT levels were enhanced. (D) Finally, non-survivors presented with significantly increased TnT levels than did survivors. Data depict median and quartiles. In (A,B) two data points (TnT; subject 52: 2,577 ng/ml; subject 61: 257 ng/ml) in the groups depicting the presence of thorax trauma and lung contusion are not shown for better visualization. In (C) one data point (TnT; subject 61: 257 ng/ml) in the group with a SOFA score ≥ 2 is not shown for better visualization.