Pedi gu review renal trauma


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Pedi gu review renal trauma

  1. 1. Renal Trauma Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  2. 3. Pediatric Renal Trauma <ul><li>Most commonly injured abdominal organ in blunt trauma </li></ul><ul><ul><li>Fetal lobulations predispose to renal separation </li></ul></ul><ul><ul><li>Less protection by pliable thoracic cage and less developed musculature </li></ul></ul><ul><ul><li>Higher incidence of pedicle injury </li></ul></ul><ul><li>80% with renal injury have associated nonrenal injuries </li></ul>
  3. 4. Pediatric Renal Trauma <ul><li>Shock unreliable indicator of significant injury </li></ul><ul><li>Controversy exists when to image pediatric renal trauma patients. </li></ul><ul><li>Some advocate imaging ALL children with microscopic hematuria </li></ul><ul><li>Dr. Morey and others have suggested observation in stable patients with <50rbc/hpf and mild trauma </li></ul>
  4. 5. Mechanisms of Injury <ul><li>Blunt trauma </li></ul><ul><ul><li>85-95% of renal trauma </li></ul></ul><ul><ul><li>Direct blow / Assault </li></ul></ul><ul><ul><li>Bony spicules of ribs or vertebrae </li></ul></ul><ul><ul><li>MVA: speed; driver, passenger, degree of deceleration </li></ul></ul><ul><ul><li>Falls </li></ul></ul>Giambologna, Hercules and the Centaur, 1550
  5. 6. Mechanisms of Injury <ul><li>Penetrating trauma </li></ul><ul><ul><li>~ 10% of renal trauma </li></ul></ul><ul><ul><li>Gunshot injury from bullet, </li></ul></ul><ul><ul><li>fragments, or blast effect </li></ul></ul><ul><ul><li>Stab wounds: size of knife </li></ul></ul><ul><ul><li>KE = ½ MV 2 </li></ul></ul>Mantegna, St. Sebastian, 1470
  6. 7. Pediatric Renal Trauma <ul><li>Preexisting renal abnormalities (i.e. UPJ Obstruction, hydro, horseshoe kidney) are 3-5 X more common in peds patients undergoing screening CT for trauma than in adults </li></ul><ul><li>Classically, congenital renal abnormality presents with hematuria disproportionate to severity of trauma </li></ul>( Chopra et al, 2002 ; McAleer et al, 2002 ; Heyns, 2004 ; Santucci et al, 2004 ).
  7. 8. American Association for the Surgery of Trauma Organ Injury Severity Scale for the Kidney Moore, Shackford, J Trauma, 1989 Grade Description of Renal Injury I  Contusion : hematuria with normal radiological studies. Hematoma : subcapsular and non expanding.  II  Hematoma  : perirenal ,confined to retroperitoneum.  Laceration  :  < 1 cm depth without extravasation III Laceration  :  > 1cm depth without collecting system injury or extravasation.  IV Laceration : through renal cortex, medulla, collecting system.    Vascular : renal artery or vein injury : contained hemaorrhage.  V Laceration : shattered destroyed kidney    Vascular    : renal arterial and venous avulsion. 
  8. 9. Organ Injury Scale
  9. 10. Hematuria in Children <ul><li>Unreliable in determining who to screen for renal injuries </li></ul><ul><li>Some studies have failed to find any evidence of either gross or microscopic hematuria in up to 70% of children sustaining grade 2 or higher renal injury. </li></ul><ul><li>Hematuria alone cannot determine need for radiographic studies </li></ul>( Morey et al, 1996 ; Buckley and McAninch, 2004 ).
  10. 11. Radiographic Trauma Assessment <ul><li>1. All penetrating abdominal trauma, </li></ul><ul><li>2. Blunt trauma victims who have either: </li></ul><ul><li>Significant deceleration or high-velocity injury </li></ul><ul><li>fractures of thoracic rib cage, spine, pelvis, or femur, or bruising of the torso/perineum, or signs of peritonitis   </li></ul><ul><li>Gross hematuria </li></ul><ul><li>Microscopic hematuria (>50 red blood cells per high-powered field) and shock (SBP<90mm Hg) </li></ul>Santucci and associates (2004a)
  11. 12. J Pediatr Surg. 2002 May;37(5):779-82 Chopra P , et al. ( Montreal, Quebec) <ul><ul><li>PURPOSE: quantify pathologic lesions of the kidney found incidentally during blunt trauma w/u </li></ul></ul><ul><ul><li>METHODS: Retrospective review of 103 patients (0 to 18 years) with blunt renal injuries. </li></ul></ul><ul><ul><li>US in all cases and CT as indicated </li></ul></ul><ul><ul><li>RESULTS: Coexisting urogenital lesions were identified in 13 of 103 (12.6%) patients, and 7 (54%) required surgical treatment. </li></ul></ul><ul><ul><li>Majority - 9 of 13 (69%) suffered minimal trauma. </li></ul></ul><ul><ul><li>Gross hematuria was main symptom. </li></ul></ul><ul><ul><li>UPJ Obstruction was most common anomaly </li></ul></ul><ul><ul><li>CONCLUSIONS: Pathologic lesions of the urinary tract are uncommon; however, they may complicate an otherwise negligible renal trauma. </li></ul></ul>
  12. 13. Brown SL , et al. in World J Surg. 2001 Dec;25(12):1557-60 Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria. <ul><ul><li>Reviewed 1200 children with blunt abdominal trauma, 35 had CT </li></ul></ul><ul><ul><li>Results </li></ul></ul><ul><ul><li>3 with grade II-V renal injuries, 32 were normal or had renal contusions </li></ul></ul><ul><ul><li>1/3 patients with gross hematuria evaluated with CT sustained significant renal injury without other associated injuries. </li></ul></ul><ul><ul><li>Conclusions: </li></ul></ul><ul><ul><li>The degree of hematuria did not correlate with the grade of renal injury. </li></ul></ul><ul><ul><li>Pediatric patients with blunt trauma, microscopic hematuria, and no associated injuries do not require radiologic evaluation, as significant renal injuries are unlikely. </li></ul></ul><ul><ul><li>However, children who present with associated injuries and microscopic hematuria after blunt trauma may have significant renal injuries and should undergo radiologic evaluation. </li></ul></ul>
  13. 14. <ul><li>Methods: </li></ul><ul><ul><li>14,763 pts reviewed </li></ul></ul><ul><li>Results: </li></ul><ul><ul><li>193 with imaging or direct evidence of renal injury at surgery (32) </li></ul></ul><ul><ul><li>69% had associated injuries </li></ul></ul><ul><ul><li>17 (8.3%) congenital GU anomalies found in series </li></ul></ul><ul><li>CONCLUSIONS: </li></ul><ul><ul><li>1.3% of pediatric trauma pts have renal injuries </li></ul></ul><ul><ul><li>8.3% had congenital anomalies </li></ul></ul><ul><ul><li>UPJ Obstruction was most common abnormality (~33%) </li></ul></ul><ul><ul><li>Congenital anomalies may not increase risk of morbidity due to renal trauma </li></ul></ul>
  14. 15. Master, McAnich; Urol Clin N Am, 2006
  15. 16. Master, McAnich; Urol Clin N Am, 2006
  16. 17. Master, McAnich; Urol Clin N Am, 2006
  17. 18. Master, McAnich; Urol Clin N Am, 2006
  18. 19. Master, McAnich; Urol Clin N Am, 2006