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Evidence-Based Management Of Pediatric Genitourinary Tract Injuries In The ED (Trauma CME)
May 2010
Abstract
In the ED, 10% of patients who present with abdominal trauma may have genitourinary injuries.1-3 Injuries to the urinary tract can involve (in order of frequency) the kidneys, bladder, urethra, and ureter.1,3,4 Trauma to the back, flank, lower thorax, or upper abdomen can cause renal injuries, 80% to 95% of which are due to blunt trauma.1,8-12 Rapid deceleration from motor vehicle collisions is the most common cause of blunt trauma.13 Hemodynamically stable patients with hematuria and suspected urinary tract injury are best evaluated by contrast-enhanced computed tomography (CT).
The pediatric kidney is more vulnerable to injury because of less protection from a pliable pediatric rib cage, abdominal muscles which are weaker, larger kidney size in the infant and toddler in proportion to the rest of the body, less perirenal fat, and presence of congenital abnormalities. Residual fetal lobulations of the kidneys allow for increased risk or renal parenchymal laceration after blunt trauma.
Ten percent of renal injuries are from penetrating trauma.1,8 Minor injuries account for 85% of total renal injures, lacerations in 10%, and severe renal ruptures, fractures, or pedicle injuries in 3% of cases.14 Renal trauma was associated with multiple other injuries in 51% to 80% of cases; head and skeletal injuries are the most common of the associated injuries.15-17
It is important to diagnose the extent and type of renal injury accurately to ensure adequate treatment. Computed tomography scanning with contrast enhancement is the modality of choice for renal trauma because it offers a quick and accurate way of demonstrating injury to the renal parenchyma, renal pedicles, and associated abdominal or retroperitoneal organs.18 If CT scanning is not an available mode for evaluating stable patients, an intravenous pyelogram is an alternative. Though renal ultrasound is increasing in popularity, its efficacy has not yet been proven and reliability and reproducibility depend on the operator and interpreter of the images.19
Over the years, the nonoperative management of blunt abdominal trauma in children with solid-organ injuries has evolved. There is a broad consensus in favor of less invasive procedures and more conservative management of traumatic renal injuries if the patient is stable; the exception would be cases of severe injury, such as injury to the vascular pedicle or complete laceration of the ureteropelvic junction.20-22
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