Pediatric emergency medicine trisk 3314 3314
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Obtain a urinalysis in all patients with multisystem trauma or suspected
isolated renal injury.
Management/Diagnostic Testing
Hemodynamically stable patients who present with suggestive clinical findings,
gross hematuria, microscopic hematuria of more than 50 RBCs/hpf, major
associated injuries, or a history of significant deceleration injury should undergo
radiographic evaluation. Obtain a contrast-enhanced CT scan with delayed
images. Children who remain unstable despite resuscitative measures should
undergo a one-shot IVP before emergency laparotomy. Children with isolated
microscopic hematuria of less than 50 RBCs/hpf do not require immediate
imaging. These patients may be discharged and can be evaluated on an outpatient
basis with CT, IVP, or ultrasound if hematuria persists. However, in some
pediatric trauma centers, management of these patients involves hospitalization
for observation, followed by nonemergent radiographic evaluation.
The diagnostic performance of imaging modalities as they relate to the
evaluation of renal trauma is reviewed below:
Computed Tomography
Contrast-enhanced CT with additional 10-minute delayed scan is the “gold
standard” imaging modality for staging a stable trauma patient. The delayed scan
or “excretory” phase, occurs after contrast has passed into the renal pelvis and
ureter, allowing better definition and evaluation of these structures. Trauma
patients lacking radiographic signs of renal injury who do not have any
perinephric, periureteral, or pelvic fluid collections do not require delayed
imaging per expert consensus. If any of these subtle findings, especially lowdensity fluid tracking around the kidney and down the ureter, are present on the
initial contrast-enhanced CT, delayed scan is indicated. A UPJ or a ureteral injury
can easily be missed if delayed images are not obtained.
The diagnostic accuracy of CT scan has been reported to be as high as 98% (
Fig. 108.3 ).
The ability of CT to quickly evaluate solid organ and vascular injuries has
significantly improved the management of trauma. Important radiologic findings
that should be noted when reviewing CT for renal trauma include arterial medial
extravasation of contrast, denoting a severe arterial injury; medial hematoma
without arterial extravasation, often secondary to a venous injury; differential
contrast uptake and excretion, which is indicative of arterial injury or thrombosis;
cortical rim sign, often indicative of a main renal artery injury; degree of
parenchymal laceration and involvement of the collecting system; degree of
