Pediatric emergency medicine trisk 3319 3319
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In cases of blunt trauma, children with grade I renal injuries (contusions) can be
discharged home without further imaging and followed with serial urinalyses.
Patients are instructed to limit daily activity until the urinalysis is within normal
limits. Outpatient radiographic evaluation is necessary if microscopic hematuria
persists for more than 30 days.
Grade II and III renal injuries warrant admission to the hospital for a minimum
of 24 hours when the risk of bleeding is highest. Expectant treatment includes
supportive care with bed rest, hydration, antibiotics, and serial hematocrits,
although the evidence supporting these therapies is relatively low. Once the gross
hematuria resolves, these children may be discharged home with limited activity
until microscopic hematuria resolves and repeat imaging demonstrates total
healing.
Management of the remaining patients (with grade IV and V injuries) evokes
significant controversy. The shift from early operative intervention to a more
expectant approach for most solid organ injuries has been increasingly applied to
high-grade renal injuries. Advocates of early surgical exploration argue that this
approach results in decreases in morbidity, hospital stay, and complications
without a significant increase in the risk for nephrectomy. Opponents believe that
nonoperative management of selected patients does not lead to negative
consequences, may result in a higher renal salvage rate, and cuts down the
morbidity associated with surgical exploration.
Nonoperative management requires admission to the hospital, serial
examinations, and hematocrits. Debate continues regarding the necessity of repeat
CT scan at 36 to 72 for conservatively managed renal injuries. According to
expert opinion, repeat imaging is not required for grade I and II injuries and grade
III injuries without hemodynamic instability or devitalized fragments. Some
authors are now beginning to advocate against routine repeat imaging for grade
IV or V renal injuries when there is no clinical indication (e.g., sepsis, decrease in
hematocrit, unstable blood pressure, increasing hematuria or oliguria), arguing
that repeat scans rarely change the management of this population and that
kidneys with stable or improved appearance on repeat CT still have a delayed
complication rate of 25%.
Patients who demonstrate hemodynamic instability require surgical
intervention or angiographic embolization of renal vessels. Angioembolization
should be performed only in those children who have a definable segmental artery
injury. Persistent urinary extravasation can be managed with percutaneous
drainage or internal ureteral stenting. These procedures, as well as embolization,
should be limited to institutions that can provide appropriate resources.
