Pediatric emergency medicine trisk 828

Resuscitation and Stabilization
A General Approach to the Ill or Injured Child: Chapter 7
Signs and Symptoms
Inguinal Masses: Chapter 39
Pain: Scrotal: Chapter 61
Vaginal Bleeding: Chapter 79
Vaginal Discharge: Chapter 80
Medical, Surgical, and Trauma Emergencies
Genitourinary Emergencies: Chapter 119

GOALS OF EMERGENCY THERAPY
The goal of emergency therapy for genitourinary injury is to maximize organ
preservation and minimize future morbidity.
To achieve these goals, the initial management of children with genitourinary
injury in the ED centers on prompt recognition and staging of injuries, followed
by appropriate urologic consultation for management and potential surgical
intervention. The recognition and treatment of children with genitourinary injury
requires an understanding of the mechanism of injury as well as signs and
symptoms associated with genitourinary injury along with appropriate use of
diagnostic imaging. To provide a comprehensive and accessible guide for
management of children with genitourinary injury, we discuss trauma of each
genitourinary organ separately yet emphasize the potential for concomitant
extrarenal injury and need for maintaining a high level of suspicion for these
associated injuries.

KIDNEY
Goal of Treatment
The principle underlying the management of pediatric renal trauma is
preservation of renal tissue and function while minimizing morbidity and
mortality. Patients who are hemodynamically unstable or have sustained severe
penetrating trauma to the kidney require immediate surgical intervention.

Management of hemodynamically stable children proceeds on the basis of
radiographic staging of the traumatic injury.
CLINICAL PEARLS AND PITFALLS


In the adult population, radiographic evaluation is required in patients
with hypotension, penetrating injuries in the vicinity of urologic organs,
associated abdominal injuries, or the presence of any degree of
hematuria. Criteria regarding the imaging of children with penetrating
trauma are less well established.
Hypotension is not a reliable indicator of significant renal injury in
children and therefore is not used to guide management; however, most
patients with multisystem trauma and hypotension undergo an abdominal
computed tomographic (CT) scan screening that elucidates both
nonurologic and urologic injuries.
Radiographic evaluation of the pediatric genitourinary tract is
necessary in cases with clinical signs indicative of renal injury, gross
hematuria, major associated injuries, or history of significant deceleration
forces. For blunt abdominal trauma, imaging is considered in any stable
child with gross hematuria or significant microscopic hematuria (>50 red
blood cells per high power field) associated with shock (systolic blood
pressure <90 mm Hg). However, the late manifestations of shock in
children with traumatic injuries have led many experts to recommend
imaging in any stable child with microscopic hematuria >50 red blood
cells with or without shock. Additionally, any child with a significant
associated injury or a suspicious mechanism of injury such as a rapid
deceleration, high velocity strike, fall from >15 ft, or a direct blow to the
abdomen or flank should be imaged regardless of the presence of
hematuria. All clinically stable children with penetrating abdominal or
pelvic trauma should undergo radiographic assessment. Stable blunt

trauma patients with microscopic hematuria may be observed without
imaging, unless they suffered a major acceleration or deceleration injury
such as a fall from a great height or high-speed MVC.


FIGURE 108.1 Algorithm for the evaluation of the pediatric patient with genitourinary trauma.
IVP, intravenous pyelogram; CT, computed tomography; RBC, red blood cell; HPF, highpowered field; UAs, urinalyses.

Current Evidence
Approximately half of all genitourinary injuries involve the kidney. Most
pediatric renal trauma is minor, requiring no intervention. Children are more
likely than adults to sustain renal injuries for the following reasons: The pediatric
kidney is larger in proportion to the size of the abdomen than in adults; the child’s
kidney may retain fetal lobations which allow for easier parenchymal disruption;
the pediatric kidney has inadequate protection due to weaker abdominal
musculature, a less well-ossified thoracic cage, and less developed perirenal fat
and fascia than in adults.


Blunt trauma accounts for more than 90% of renal injuries in children. The
majority result from motor vehicle accidents; falls, sports-related incidents, and
direct blows are also common mechanisms of injury. In these scenarios, the
kidneys are crushed against the ribs or vertebral column from their relatively
fixed position within Gerota fascia. Injuries include contusions, renal lacerations,
and rarely stretching of the vascular pedicle causing renal vein or artery injuries.
Penetrating trauma accounts for the 10% of remaining cases. Approximately 10%
of penetrating abdominal injuries involve the kidney.
Minor renal injuries account for 85% of total injuries, lacerations in 10%, and
severe kidney ruptures, fractures of pedicle injuries in less than 5% of cases.
Associated extrarenal injuries often occur, with head injuries being the most

common. Associated intraperitoneal injuries occur in 80% of patients with
penetrating renal trauma and 20% of patients with blunt renal trauma. In general,
the hospital length of stay is determined by the associated injuries and not the
renal injuries.
Historically, pre-existing anomalies have been believed to increase the risk and
severity of injury to the kidney. Coincidental congenital renal anomalies and
intrarenal tumors have been reported in up to 20% of children with renal injuries.
However, it appears that in most patients, congenital genitourinary anomalies
associated with renal injury are incidental findings and do not increase morbidity.
More accurate recent reviews show that the incidence rate is closer to 1%.
Nevertheless, a high index of suspicion should be maintained in any child who
presents with gross hematuria after a relatively minor trauma. Other patients may
present with an acute abdomen due to intraperitoneal rupture of a hydronephrotic
kidney.

Clinical Considerations
Clinical Recognition
Children who sustain significant renal injuries usually present with localized
signs such as flank tenderness, hematoma, palpable mass, or ecchymosis.
However, since kidney injuries are often associated with injuries to other organs,
generalized abdominal tenderness, rigidity of the abdominal wall, paralytic ileus,
and hypovolemic shock may all be part of the clinical picture. Penetrating injuries
to the chest, abdomen, flank, and lumbar regions should alert the clinician to the
possibility of a renal injury.
Hematuria has long been considered the cardinal marker of renal injury and
98% of pediatric patients suffering a renal injury will have some degree of
hematuria. However, the degree of hematuria does not correlate with the severity