Pediatric Trauma
RENAL INJURY
2/3 of children may have a normal urinalysis even after sustaining Grade II or higher renal injuries. (1,5,6,7,8) Hemodynamic instability and the absence of hematuria are unreliable markers of the absence of renal injury in children. Mandatory radiographic evaluation for renal trauma includes the presence of gross hematuria, microscopic hematuria (>50 RBC/hpf after blunt trauma or > 5 RBC/hpf after penetrating trauma) with shock, a significant deceleration injury (fall or motor vehicle accident), trauma resulting in physical signs concerning for renal injury (including flank ecchymosis and rib injury) and/other mechanism of injury concerning for renal trauma. (1,2,3,6) Microscopic hematuria alone after a blunt trauma is not an indication for imaging in children. IVP performed by injecting 2 ml/kg of contrast followed by an abdominal x-ray taken 10-15 minutes later. Hypertension 30 days after a renal injury may be caused by arteriovenous fistula, pseudoaneurysm or perinephric scarring. (4,7)
URETHRAL INJURIES
Circumcision urthral injuries should be repaired in the operating room with fine absorbable sutures to prevent meatal stenosis or contraction. Postoperative urinary drainage is often not necessary, and the wound can be managed with topical antibiotic ointment. Female urethral patients (who are stable) should undergo immediate urethroplasty with realignment of the urethra, repair of the bladder neck injury and vaginal laceration, as well as a diverting colostomy if a rectal injury is identified. (1)
BLADDER INJURIES
For cystogram imaging, the amount of contrast instilled into a child, should be at least one-half of the estimated bladder capacity calculated for the child's age [(age + 2) x 30 ml)]. Absolute indications for bladder imaging after a blunt abdominal injury are (1) the presence of gross hematuria coexisting with a pelvic fracture and (2) inability to void. Relative indications for bladder imaging after blunt trauma include urinary clot retention, perineal hematoma and a history of prior bladder augmentation. Because of the nature of the immature pelvis in children, any blunt trauma with a fracture of the pubic rami, especially when associated with diastasis of the pubic symphysis, requires complete radiographic evaluation. (1,9)
2/3 of children may have a normal urinalysis even after sustaining Grade II or higher renal injuries. (1,5,6,7,8) Hemodynamic instability and the absence of hematuria are unreliable markers of the absence of renal injury in children. Mandatory radiographic evaluation for renal trauma includes the presence of gross hematuria, microscopic hematuria (>50 RBC/hpf after blunt trauma or > 5 RBC/hpf after penetrating trauma) with shock, a significant deceleration injury (fall or motor vehicle accident), trauma resulting in physical signs concerning for renal injury (including flank ecchymosis and rib injury) and/other mechanism of injury concerning for renal trauma. (1,2,3,6) Microscopic hematuria alone after a blunt trauma is not an indication for imaging in children. IVP performed by injecting 2 ml/kg of contrast followed by an abdominal x-ray taken 10-15 minutes later. Hypertension 30 days after a renal injury may be caused by arteriovenous fistula, pseudoaneurysm or perinephric scarring. (4,7)
URETHRAL INJURIES
Circumcision urthral injuries should be repaired in the operating room with fine absorbable sutures to prevent meatal stenosis or contraction. Postoperative urinary drainage is often not necessary, and the wound can be managed with topical antibiotic ointment. Female urethral patients (who are stable) should undergo immediate urethroplasty with realignment of the urethra, repair of the bladder neck injury and vaginal laceration, as well as a diverting colostomy if a rectal injury is identified. (1)
BLADDER INJURIES
For cystogram imaging, the amount of contrast instilled into a child, should be at least one-half of the estimated bladder capacity calculated for the child's age [(age + 2) x 30 ml)]. Absolute indications for bladder imaging after a blunt abdominal injury are (1) the presence of gross hematuria coexisting with a pelvic fracture and (2) inability to void. Relative indications for bladder imaging after blunt trauma include urinary clot retention, perineal hematoma and a history of prior bladder augmentation. Because of the nature of the immature pelvis in children, any blunt trauma with a fracture of the pubic rami, especially when associated with diastasis of the pubic symphysis, requires complete radiographic evaluation. (1,9)
- AUA Core Curriculum. Pediatric Trauma. Accessed 9/10/2018
- Russell RS, Gomelsky A, McMahon DR, Andrews D, Nasrallah PF. Management of grade IV renal injury in children. Journal of urology. Sep 2001;166(3):1049-1050.
- Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal MR. Validation of the American Association for the Surgery of Trauma organ injury severity scale for the kidney. The Journal of trauma. Feb 2001;50(2):195-200.
- Chedid A, Le Coz S, Rossignol P, Bobrie G, Herpin D, Plouin PF. Blunt renal trauma-induced hypertension: prevalence, presentation, and outcome. American journal of hypertension. May 2006;19(5):500-504.
- Buckley JC, McAninch JW. Pediatric renal injuries: management guidelines from a 25-year experience. Journal of urology. Aug 2004;172(2):687-690.
- Buckley JC, McAninch JW. The diagnosis, management, and outcomes of pediatric renal injuries. The Urologic clinics of North America. Feb 2006;33(1):33-40, vi.
- Santucci RA, Wessells H, Bartsch G, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee. BJU international. May 2004;93(7):937-954.
- Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. Journal of urology. Dec 1996;156(6):2014-2018.
- Simhan J, Rothman J, Carter D, Reyes J, Jaffe W, Pontari M, et al. Gunshot wounds to the scrotum: a large single-institutional 20-year experience. BJU International. 2012 Jun 1;109(11):1704–7.