Pediatric emergency medicine trisk 3320 3320
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Operative exploration is required in 5% to 10% of cases. Absolute indications
for renal exploration are life-threatening hemorrhage believed to be from renal
injury, renal pedicle avulsion and expanding, pulsatile or uncontained
retroperitoneal hematoma. Relative indications include incomplete radiographic
staging with concurrent traumatic injuries that require repair/exploration,
extensive devitalized renal parenchyma, vascular injury, and significant urinary
extravasation. Attempts to preserve the kidney are more likely to succeed in
patients with grade IV injuries. Children with grade V injuries frequently require
nephrectomy. In patients with vascular injuries, chances of renal salvage are
improved if renal parenchyma is minimally disrupted and revascularization is
achieved within a few hours of the injury.
Penetrating renal injuries have traditionally been managed with operative
intervention. Compared with blunt trauma, far less literature is available in
support of nonoperative treatment after penetrating trauma. In addition, many
recommendations are extrapolated from data on adult patient populations. Careful
selection of hemodynamically stable patients who can tolerate CT staging may
identify a cohort of children who can be safely treated conservatively. Indications
for renal exploration are similar to those for injuries caused by blunt trauma.
Patients with penetrating trauma have a higher need for surgical intervention.
Short-term complications of renal trauma include delayed hemorrhage, urinary
extravasation, abscess formation, and ureteral obstruction secondary to clot
formation. Drainage with a ureteral stent or percutaneous nephrostomy may be
considered in cases of ongoing urinary extravasation.
Long-term complications include compromised renal function, hypertension,
and arteriovenous fistula. Chronic hypertension develops in a period ranging from
2 days to 32 years, which is why patients with a history of renal trauma should
undergo long-term yearly blood pressure monitoring.
URETER
Goal of Treatment
Ureteral injuries are uncommon in children and are often missed on initial
evaluation. As the ureters are well protected in the retroperitoneum, significant
concomitant injuries are usually present. The goal of emergency evaluation is to
recognize the clinical scenarios in which ureteral trauma is possible so as to allow
high suspicion for these injuries and prompt operative intervention. These injuries
occur in less than 1% of all genitourinary traumas.
