Pediatric emergency medicine trisk 2913 2913
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This can provide a valuable assessment of the renal parenchyma and the
urologic tract. Ultrasound can detect such disorders as renal dysplasia, renal
cortical thinning consistent with reflux nephropathy, cystic kidney disease,
urinary tract obstruction, and screen for renal vascular disease. Kidneys that
appear relatively normal in architecture but enlarged, are suggestive of an
acute or reversible process. Small kidneys would be consistent with a
chronic process and parenchymal scarring. Imaging requiring IV contrast
including gadolinium may worsen renal injury and should be avoided when
possible or used in conjunction with consultation of a pediatric nephrologist
or radiologist.
Management. The treatment of children with CKD can range from
routine care to intensive management. If a child with CKD presents to the
ED with a significant illness, treatment should be coordinated with a
pediatric nephrologist when possible. The initial approach should identify
reversible causes of decreased renal function, such as intravascular volume
depletion and use of nephrotoxic medications (i.e., NSAIDs). Children who
have decreased effective circulating volume should be provided IV isotonic
fluid if oral hydration is expected to be insufficient or not well tolerated.
Bolus IV fluid can be provided at 10 mL/kg and should be followed by
repeated assessment to determine if further IV fluid is warranted. Patients
presenting in shock may require more aggressive fluid resuscitation.
Subsequent fluid rates should be provided on the basis of ongoing losses
and urine flow to ensure adequate perfusion and avoid volume excess.
With severe decline in GFR, sodium and water retention may develop
and lead to clinical signs of volume overload. Diuretic therapy should be
trialed for treatment of clinical volume overload, although it may not be
adequately effective. Furosemide at a dose of 0.5 to 1 mg/kg may be given
intravenously, recognizing that higher doses may be required to achieve the
desired effect for those with more severe renal dysfunction. For children
with sustained hypertension, therapy will depend on the degree and the
chronicity of elevation. Severe hypertension with end organ dysfunction or
concern for impending end organ dysfunction should be treated with shortacting IV antihypertensive medications such as hydralazine, β-blockers
such as esmolol and labetalol, or calcium channel blockers. The goal of
therapy is to lower the blood pressure by 20% to 30% or to a range that is
not acutely dangerous within the first 2 to 3 hours. Blood pressure can then
