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Renal Trauma. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, MO. Renal Trauma. Trauma is most common cause of death in children Injuries to the kidneys account for 60% of genitourinary injuries 90% blunt trauma Usually do not require operation

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renal trauma

Renal Trauma

George W. Holcomb, III, M.D., MBA

Surgeon-in-Chief

Children’s Mercy Hospital

Kansas City, MO

renal trauma1
Renal Trauma
  • Trauma is most common cause of death in children
  • Injuries to the kidneys account for 60% of genitourinary injuries
    • 90% blunt trauma
    • Usually do not require operation
  • 10-20% penetrating trauma
    • More often require operation
  • Deceleration/flexion injuries
    • Produce renal arterial or venous injuries
renal trauma2
Renal Trauma
  • Due to their size and location, kidneys are susceptible to injury from blunt trauma
  • Children are more susceptible than adults to major renal injury
    • Less perirenal fat
    • Weaker abdominal musculature
    • Less well-ossified thoracic cage
  • Kidneys with congenital abnormalities are at increased risk of injury
  • Pediatric evaluation and treatment guidelines not clearly defined for children
renal trauma3
Renal Trauma
  • Standard Imaging Modality – (U.S.)
    • CT scan often performed in trauma w/u
    • CT scan recommended in patients with hematuria
    • Ultrasound may be used to screen hemodynamically unstable patients
      • FAST 95% specificity, but 33-89% sensitivity
renal trauma4
Renal Trauma
  • Management goal: renal salvage
  • Indications for immediate exploration
    • Hemodynamic instability
    • Penetrating injury – unstable patient
    • Associated non-renal injuries
  • Nephrectomy required in less than 10% of cases
  • Isolated penetrating renal injury in stable patient can be managed conservatively
    • Aggressive radiologic, laboratory and clinical efforts important in managing patients w/o operation
renal trauma5
Renal Trauma
  • Stable grade I-III injuries
    • Managed non-operatively
  • Severe grade IV-V
    • Require careful selection based on
      • hemodynamic stability
      • mechanism
      • associated non-renal injuries
    • Stable patients may need monitoring in ICU setting
renal trauma6
Renal Trauma
  • Management
    • Inconclusive data
    • Antibiotics
      • Likely only needed when stent placed
    • Bedrest
      • Variable practice: bedrest for 5-7 days, or until hematuria clears, or once physically able
      • No consensus
renal trauma7
Renal Trauma
  • Management
    • Ureteral stent indications
      • 80% of grade IV and V collecting system injuries heal without intervention
      • If collecting system extravasation does not resolve within two weeks, stenting is then considered
      • Symptomatic urinomas may require stenting
      • Lack of contrast in ipsilateral ureter may indicate significant injury, necessitating stent
renal trauma8
Renal Trauma
  • Complications
    • Hypertension
      • Estimated incidence: 0 - 7.5%
  • Follow-up imaging
    • Little data to support its use
children s mercy 1995 2007
Children’s Mercy1995 - 2007
  • All patients with blunt renal trauma
    • Mean age 11 yrs
    • MVC - 44%
    • Falls - 30%
    • Sports - 22%
  • Grade I - 26%

Grade II - 23%

Grade III - 35%

Grade IV - 13%

Grade V - 3%

J PediatrSurg 45:1311-1314, 2010

children s mercy
Children’s Mercy
  • Isolated renal injury - (44%)
    • Bed rest - 3.8 ± 1.9 d (mean)
    • Hospital - 3.8 ± 3.1 d (mean)
  • Blood tx – 15 pts
    • Mean vol – 700 c
    • Op – 6 pts – None for renal injury
    • No tx in isolated renal injury
    • No tx Grade IV or V injury
  • Renal salvage – 99.1%
    • One nephrectomy in pt w/ESRD
  • HTN – 3 pts – 1 resolved
  • Urinoma – 1 pt – resolved w/drainage

J PediatrSurg 45:1311-1314, 2010

renal trauma9
Renal Trauma
  • CMH is currently participating in multi-institutional, prospective, randomized trial with long-term follow-up
    • Patients allowed out of bed when physically able
    • Daily UA while in hospital
    • Once discharged, weekly UA until hematuria is cleared
    • Discharged when patients meet general discharge criteria
    • 3 year follow-up for hypertension
references
References
  • Fraser, JD, Aguayo P, Ostlie DJ, et al: Review of the evidence on the management of blunt renal trauma in pediatric patients. Pediatr Surg Int (2009) 25:125-132.
  • Holcomb GW III, Murphy JP. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia, PA: Saunders An Imprint of Elsevier, 2010.
  • Nerli RB, Metgud T, Patil S, et al: Severe renal injuries in children following blunt abdominal trauma: selective management and outcome. Pediatr Surg Int (2011) 27:1213-1216
  • Suson KD, Gupta AD, Wang MH. Bloody urine after minor trauma in a child: isolated renal injury versus congenital anomaly? J Pediatr. (2011) 159:870.
questions
QUESTIONS

www.cmhclinicaltrials.com