Pediatric emergency medicine trisk 2886 2886
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physical function related to volume overload. Other presenting symptoms
of AKI may be nonspecific such as malaise and nausea. In other instances,
the initial complaint will be related to an underlying systemic or infectious
cause for the AKI.
Triage considerations. AKI includes a wide spectrum of disease and
severity. Initial triage should be based on overall clinical appearance and
hemodynamic stability. Patients with hypertensive crisis, respiratory
distress from volume overload, or life-threatening dysrhythmias from
electrolyte disturbances warrant emergent stabilization. Children with more
mild presentations may undergo further evaluation into underlying causes at
the onset.
Clinical assessment. A thorough history is necessary to reveal the
underlying etiology of AKI. A detailed history of fluid balance should be
obtained. The quality and quantity of urine should be identified. Recent
medications should be reviewed to identify potential causes of drug-induced
nephrotoxicity. Important classes of medications that increase the risk for
AKI include nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensinconverting enzyme (ACE) inhibitors, angiotensin II receptor blockers
(ARBs), aminoglycoside antibiotics, and calcineurin inhibitors.
The patient should be evaluated for hypertension, and the physical
examination should assess hydration status and perfusion as well as
evaluate for edema and evidence of third spacing. The patient’s weight
should be compared to a “dry weight” or recent weight prior to the onset of
illness, when possible. The examination may reveal signs of systemic
vasculitis associated with nephritis, such as rashes or arthritis. The presence
of a palpable bladder or mass, which may be compressing the urinary tract
or stemming from the kidneys themselves, should be assessed for during the
abdominal examination.
Laboratory assessment of AKI serves two purposes. First, it should
determine the severity of renal dysfunction and identify associated
electrolyte, metabolic, or hematologic abnormalities, which may require
urgent intervention. Secondly, a focused investigation should be aimed at
determining the underlying cause of AKI based on the clinical presentation
of the patient. Initial serum laboratory studies should include serum
creatinine, electrolytes, and complete blood cell counts. Children with AKI
may demonstrate hyperkalemia, hypo- or hypernatremia, AG acidosis,
