Trauma Pediatric - part 8 pptx

19. Morse MA, Garcia VF. Selective nonoperative management of pediatric blunt splenic trauma: risk for missed associated injuries. J Pediatr Surg 1994; 29:23–27. 20. Nance ML, Keller MS, Stafford PW. Predicting hollow visceral injury in the pediatric blunt trauma patient with soild visceral injury. J Pediatr Surg 2000; 35:1300–1303. 21. Miller K, Kou D, Stallion A, Dudgeon DL, Grisoni ER. Pediatric hepatic trauma: does clinical course support intensive care unit stay? J Pediatr Surg 1998; 33:1459–1462. 22. Reuss L, Sivit CJ, Eichelberger MR, Taylor GA, Bond SJ. Blunt hepatic and splenic trauma in children: correlation of a CT injury severity scale with clinical outcome. Pediatr Radiol 1995; 25:321–325. 23. Emery KH, Babcock DS, Borgman AS, Garcia VF. Splenic injury diagnosed with CT: US follow-up and healing rate in children and adolescents. Radiology 1999; 212:515–518. 24. Lynch JM, Meza MP, Newman B, Gardner MJ, Albanese CT. Computed tomography grade of splenic injury is predictive of the time required for radiographic healing. J Pediatr Surg 1997; 32:1093–1096. 25. Benya EC, Bulas DI, Eichelberger MR, et al. Splenic injury from blunt abdominal trauma in children: follow-up evaluation with CT. Radiology 1995; 195:685–688. 26. Pranikoff T, Hirschl RB, Schlesinger AE, et al. Resolution of splenic injury after non- operative management. J Pediatr Surg 1994; 29:1366–1369. 27. Ellrodt G, Cook DJ, Lee J, et al. Evidence-based disease management. JAMA 1997; 278:1687–1692. 28. Fabian TC. Evidence-Based Medicine in Trauma Care: Whither goest thou? J Trauma 1999; 47:225–232. 29. Hoyt DB. Clinical practice guidelines. Am J Surg 1997; 173:32–34. 30. Pasquale M, Fabian TC. Practice management guidelines for trauma from the Eastern Association for the Surgery of Trauma. J Trauma 1998; 44:941–957. 31. Fallat ME, Casale AJ. Practice patterns of pediatric surgeons caring for stable patients with traumatic solid organ injury. J Trauma 1997; 43:820–824. 32. Lund DP, Zurakowski D, Atkinson C. Usual practice in the management of solid visc- eral injuries: a survey of North American pediatric surgeons. Poster presentation at the 50th Annual Meeting of the Section on Surgery of the AAP, San Francisco, CA, Octo- ber 1998. 33. Stylianos S. Controversies in abdominal trauma. Semin Pediatr Surg 1995; 4:116–119. 34. Hardin WD, Stylianos S, Lally KP. Evidence-based practice in pediatric surgery. J Pediatr Surg 1999; 34:908–913. 35. Shafi S, Gilbert JC, Carden S, et al. Risk of hemorrhage and appropriate use of blood transfusions in pediatric blunt splenic injuries. J Trauma 1997; 42:1029–1032. 36. Shilyansky J, Navarro O, Superina RA, Babyn PS, Filler RM, Pearl RH. Delayed hemorrhage after nonoperative management of blunt hepatic trauma in children: a rare but significant event. J Pediatr Surg 1999; 34:60–64. 37. Brown RL, Irish MS, McCabe AJ, Glick PL, Caty MG. Observation of splenic trauma: when is a little too much? J Pediatr Surg 1999; 34:1124–1126. 38. Norotsky MC, Rogers FB, Shackford SR. Delayed presentation of splenic artery pseu- doaneurysms following blunt abdominal trauma: case Reports. J Trauma 1995; 38: 444–447. 39. Frumiento C, Sartorelli K, Vane DW. Complications of splenic injuries: expansion of the nonoperative theorem. J Pediatr Surg 2000; 35:788–791. 40. Sanders DW, Andrews DA. Conservative management of hepatic duct injury after blunt trauma: a case report. J Pediatr Surg 2000; 35:1503–1505. 41. Hoyt DB, Bulger EM, Knudson MM, et al. Death in the operating room: an analysis of a multi-center experience. J Trauma 1994; 37:426–432. 42. Moulton SL, Lynch FP, Canty TG, et al. Hepatic vein and retrohepatic vena caval inju- ries in children: Sternotomy first? Arch Surg 1991; 126:1262–1266. 43. VanderKolk WE, Kurz P, Daniels J, et al. Liver hemorrhage during laparotomy in patients with necrotizing enterocolitis. J Pediatr Surg 1996; 31:1063–1067. 298 Stylianos et al. 44. Gross M, Lynch F, Canty T, Peterson B, Spear R. Management of pediatric liver inju- ries: a 13-year experience at a pediatric trauma center. J Pediatr Surg 1999; 34:811–817. 45. Pryor JP, Stafford PW, Nance ML. Severe blunt hepatic trauma in children. J Pediatr Surg 2001; 36:974–979. 46. Watts DD, Trask A, Soeken K, Perdue P, Dols S, Kaufmann C. Hypothermic coagulo- pathy in trauma: effect of varying levels of hypothermia on enzyme speed, platelet func- tion, and fibrinolytic activity. J Trauma 1998; 44:846–854. 47. Denton JR, Moore EE, Codwell DM. Multimodality treatment for Grade V hepatic injuries: Perihepatic packing, arterial embolization, and venous stenting. J Trauma 1997; 42:964–968. 48. Richardson JD, Franklin GA, Lukan JK, Carrillo EH, Spain DA, Miller FB, Wilson MA, Polk HC, Flint LM. Evolution in the management of hepatic trauma: a 25-year perspec- tive. Ann Surg 2000; 232:324–330. 49. Asensio JA, Demetriades D, Chahwan S, et al. Approach to the management of com- plex hepatic injuries. J Trauma 2000; 48:66–69. 50. Shapiro MB, Jenkins DH, Schwab CW, Rotondo MF. Damage control: collective review. J Trauma 2000; 49:969–978. 51. Barker DE, Kaufman HJ, Smith LA, Ciraulo DL, Richart CL, Burns RP. Vacuum pack technique of temporary abdominal closure: a 7-year experience with 112 patients. J Trauma 2000; 48:201–207. 52. Cogbill TH, Moore EE, Jurkovich GJ. Severe hepatic trauma: a multicenter experience with 1,335 liver injuries. J Trauma 1988; 28:1433–1438. 53. Hirshberg A, Mattox KL. Planned reoperation for severe trauma. Ann Surg 1995; 222:3–8. 54. Rotondo MF, Schwab CW, McGonigal MD, et al. Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma 1993; 35:375–383. 55. Stylianos S, Jacir NN, Hoffman MA, et al. Pediatric blunt liver injury and coagulopathy managed with packs and silo. J Trauma 1990; 30:1409–1410. 56. Stylianos S. Abdominal packing for severe hemorrhage. J Pediatr Surg 1998; 33:339–342. 57. Evans S, Jackson RJ, Smith SD. Successful repair of major retrohepatic vascular inju- ries without the use of shunt or sternotomy. J Pediatr Surg 1993; 28:317–320. 58. Horwitz JR, Black T, Lally KP, et al. Venovenous bypass as an adjunct for the manage- ment of a retrohepatic venous injury in a child. J Trauma 1995; 39:584–585. 59. Davies MRQ. Iatrogenic hepatic rupture in the newborn and its management by pack tamponade. J Pediatr Surg 1997; 32:1414–1419. 60. Strear CM, Graf JL, Albanese CT, Harrison MR, Jennings RW. Successful treatment of liver hemorrhage in the premature infant. J Pediatr Surg 1998; 33:849–851. 61. Adams JM, Hauser CJ, Livingston DH, Fekete Z, Hasko G, Forsythe RM, Deitch EA. The immunomodulatory effects of damage control abdominal packing on local and sys- temic neutrophil activity. J Trauma 2001; 50:792–800. 62. Saggi BH, Sugerman HJ, Ivatury RR, Bloomfield GL. Abdominal compartment syndrome. J Trauma 1998; 45:597–609. 63. Chang MC, Miller PR, D’ Agostino R, Meredith JW. Effects of abdominal decompres- sion on cardiopulmonary function and visceral perfusion in patients with intra-abdominal hypertension. J Trauma 1998; 44:440–445. 64. DeCou JM, Abrams RS, Miller RS, Gauderer MWL. Abdominal compartment syn- drome in children: experience with three cases. J Pediatr Surg 2000; 35:840–842. 65. Neville HL, Lally KP, Cox CS. Emergent abdominal decompression with patch abdo- minoplasty in the pediatric patient. J Pediatr Surg 2000; 35:705–770. 66. Ballard RB, Badellino MM, Enyon CA, Spott MA, Staz CF, Buckman RF Jr. Blunt duodenal rupture: A 6 year statewide review. J Trauma 1997; 43:729–733. 67. Shilyansky J, Pearl RH, Kroutouro M, Sena LM, Babyn PS. Diagnosis and manage- ment of duodenal injuries in children. J Pediatric Surg 1997; 32:880–886. Abdominal Trauma in Children 299 68. Winthrop AL, Wesson DE, Filler RM. Traumatic douodenal hematoma in the pediatric patient. J Pediatric Surg 1986; 21:757–760. 69. Ladd AP, West KW, Rouse TM, Scherer LR, Rescorla FJ, Enaum SH, Grosfeld JL. Surgical management of duodenal injuries in children. Surgery 2002; 132:748–753. 70. Fang JF, Chen RJ, Ling BC. Controlled reopen suture technique for pyloric exclusion. J Trauma 1998; 45:593–596. 71. Lane MJ, MindelzunRE, Jeffery RB. Diagnosis of pancreatic injury after blunt abdom- inal trauma. Semin Ultrasound CT MR 1996; 17:177–182. 72. Jobst MA, Canty TG Sr, Lynch FP. Management of pancreatic injury in pediatric blunt abdominal trauma. J Pediatric Surg 1999; 34:818–824. 73. Canty JG Sr, Weinman D. Treatment of pancreatic duct disruption in children by an endoscopically placed stent. J Pediatric Surg 2001; 36:345–348. 74. Canty TG Sr, Weinman D. Management of major pancreatic duct injuries in children. J Trauma 2001; 50:1001–1007. 75. Lucaya J, Vasques E, Caballerro F, Chait PG, Daneman A, Wesson D. Pediatric Radiol 1998; 28:5–8. 76. Shilyansky J, Sen LM, Kreller M, Chait P, Babyn PS, Filler RM, Pearl RH. Nonopera- tive management of pancreatic injuries in children. J Pediatric Surg 1999; 33:343–345. 77. Wales PW, Shuckett B, Kim PC. Longterm outcome of nonoperative management of complete traumatic pancreatic transection in children. J Pediatric Surg 2001; 36:823–827. 78. Meier DR, Coln CD, Hicks BA, Guzzetta PC. Early operation in patients with pancreas transsection. J Pediatric Surg 2001; 36:341–344. 79. McGahren ED, Magnuson D, Schauer RT, Tapper D. Management of transection of the pancreas in children. Aust NEJ Surg 1995; 65:242–246. 80. Rescorla FJ, Plumkey DA, Sherman S, Scherer LR III, West KW, Grosfeld JL. The effi- cacy of early ERCP in pediatric pancreatic trauma. J Pediatr Surg 1995; 30:336–340. 81. Harrell DJ, Vitale GC, Larson GM. Selective role for endoscopic retrograde cholangio- pancreatography in abdominal trauma. Surg Endosc 1998; 12:400–404. 82. Kim HS, Lee DK, Kim IW, Baik SN, Kwan SO, Park JW, Cho NC, Rhoe BS. The role of retrograde pancreatography in the treatment of traumatic pancreatic duct injury. Gastrointest Endocs 2001; 54:45–55. 83. Boman-Vermeeren JM, Vermeeren-Walters G, Broos P, Eggermont E. Somatastatin in the treatment of a pancreatic pseudocyst in a child. J Pediatric Gastroenterol Nutr 1996; 23:422–425. 84. Soto JA, Alvarez O, Munera F, Yepes NL, Sepulveda ME, Perez JM. Traumatic disrup- tion of the pancreatic duct: diagnosis with MR pancreatography. AM J Roentgenol 2001; 176:175–178. 85. Kouchi K, Tanabe M, Yoshida H, Iwai J, Matsunag AT, Ohtsuka Y, Kuroda H, Hishiki T, Ohavuma N. Nonoperative management of blunt pancreatic injury in chil- dren. J Pediatric Surg 1999; 34:1736–1738. 86. Moss RL, Musemeche CA. Clinical judgment is superior to diangnostic tests in the management of pediatric small bowel injury. J Pediatr Surg 1996; 8:1178–1181. 87. Jerby BL, Attorri RJ, Morton D Jr. Blunt intestinal injury in children: the role of the physical examination. J Pediatr Surg 1997; 32:580–584. 88. Ciftci AO, Tanyel FC, Salman AB, Buyukpamukeu N, Hicsonmez A. Gastrointestinal tract perforation due to blunt abdominal trauma. Pediatr Surg Int 1998; 13:259–264. 89. Chandler CF, Lane JS, Waxman KS. Seatbelt sign following blunt trauma is associated with increased incidence of abdominal injury. Am Surgeon 1997; 63:885–888. 90. Wotherspoon S, Chu K, Brown AF. Abdominal surgery and the seat-belt sign. Emerg Med (Fermantle) 2001; 13:61–65. 91. Stassen NA, Lukan JK, Carrillo EH, Spain DA, Richardson JD. Abdominal seat belt marks in the era of focused abdominal sonography for trauma. Arch Surg 2002; 137: 718–722; discussions, 722–723. 300 Stylianos et al. 92. Hara H, Babyn PS, Bourgeois D. Significance of bowel wall enhancement on CT follow- ing blunt abdominal trauma in childhood. J Computer Assisted Tomography. 1992; 16:94–98. 93. Jamieson DH, Babyn PS, Pearl R. Imaging gastrointestinal perforation in pediatric blunt abdominal trauma. Pediatr Radiol 1996; 26:188–194. 94. GrahamJS, Wong AL. A review of computed tomographyin the diagnosis of intestinal and mesenteric injury in pediatric blunt abdominal trauma. J. Pediatric Surg 1996:754–756. 95. Hulka F, Mullins RJ, Leonardo V, Harrison MW, Silberberg P. Significance of perito- neal fluid as an isolated finding on abdominal computed tomographic scans in pediatric trauma patients. J Trauma 1998; 44:1069–1072. 96. Holmes JF, London KL, Brant WE, Kuppermann N. Isolated intraperitoneal fluid on abdominal computed tomography in children with blunt trauma. Acad Emer Med 2000; 7:335–341. 97. Patel, JC, Tepas JJ III. The efficacy of focused abdominal sonography for trauma (FAST) as a screening tool in the assessment of injured children. J Pediatr Surg 1999; 34:44–47; discussion, 52–54. 98. Albanese CT, Meza MP, Gardner MJ, Smith SD, Rowe MI, Lynch JM. Is computed tomography a useful adjunct to the clinical examination for the diagnosis of pediatric gastrointestinal perforation from blunt abdominal trauma in children? J Trauma 1996; 40:417–421. 99. Ramos CT, Koplewitz BZ, Babyn PS, Manson PS, Ein SH. What have we learned about traumatic diaphragmatic hernias in children? J Pediatr Surg 2000; 35:601–604. 100. Koplewitz BZ, Ramos C, Manson DE, Babyn PS, Ein SH. Traumatic diaphragmatic injuries in infants and children: imaging findings. Pediatr Radiol 2000; 30:471–479. 101. Pitcher G. Fiber-endoscopic thoracoscopy for diaphragmatic injury in children. Semin Pediatr Surg 2001; 10:17–19. 102. Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair of traumatic dia- phragmatic hernias. Surg Endosc 2000; 14:1010–1014. 103. Sola JE, Mattei P, Pegoli W Jr, Paidas CN. Rupture of the right diaphragm following blunt trauma in an infant: case report. J Trauma 1994; 36:417–420. 104. Cohen Z, Gabriel A, Izrachi S, Kapuler V, Mares AJ. Traumatic avulsion of kidney into the chest through a ruptured diaphragm in a boy. Pediatr Emerg Care 2000; 3:180–181. 105. Stylianos S, Bergman KS, Harris BH. Traumatic renal avulsion into the chest: case report. J Trauma 1991; 31:301–302. 106. Kadish HA, Schunk JE, Britton H. Pediatric male rectal and genital trauma: accidental and nonaccidental injuries. Pediatr Emerg Care 1998; 14:95–98. 107. Reinberg O, Yazbeck S. Major Perineal trauma in children. J Pediatr Surg 1989; 24:982–984. 108. Orr CJ, Clark MA, Hawley DA, Pless JE, Tate LR, Fardal PM. Fatal anorectal injuries: a series of four cases. J Forensic Sci 1995; 40:219–221. 109. Lickstein DA, Moriary KP, Feins NR. Neonatal rectovaginal tear during cesarean sec- tion. J Pediatr Surg 1998; 33:1315–1316. 110. Cuschieri A, Hennessy TP, Stephens RB, Berci G. Diagnosis of significant abdominal trauma after road traffic accidents: preliminary results of a multicentre clinical trial comparing minilaparoscopy with peritoneal lavage. Ann R Coll Surg Engl 1988; 70:153–155. 111. Fabian TC, Croce MA, Stewart RM, Pritchard FE, Minard G, Kudsk AK. A prospec- tive analysis of diagnostic laparoscopy in trauma. Ann Surg 1993; 217:557–564; discus- sion, 564–565. 112. Simon RJ, Rabin J, Kuhls D. Impact of increased use of laparoscopy on negative lapar- otomy rates after penetrating trauma. J Traum 2002; 53:297–302; discussion, 302. 113. Smith RS, Fry WR, Morabito DJ, Koehler RH, Organ CH Jr. Therapeutic laparoscopy in trauma. Am J Surg 1995; 170:632–636; discussion, 636–637. Abdominal Trauma in Children 301 114. Chen RJ, Fang JF, Lin BC, Hsu Yb, Kao JL, Kao YC, Chen MF. Selective application of laparoscopy and fibrin glue in the failure of nonoperative management of blunt hepa- tic trauma. J Trauma 1998; 44:691–695. 115. Taner AS, Topgul K, Kucukel F, Demir A, Sari S. Diagnostic laparoscopy decreases the rate of unnecessary laparotomies and reduces hospital costs in trauma patients. J Lapar- endosc Adv Surg Tech A 2001; 11:207–211. 116. Hawegawa T, Miki Y, Yoshioka Y, Mizutani S, Sasaki T, Sumimura J. Laparoscopic diagnosis of blunt abdominal trauma in children. Pediatr Surg Int 1997; 12:132–136. 117. Gandhi RR, Stringel G. Laparoscopy in pediatric abdominal trauma. JSLS 1997; 1:349–351. 118. Chen MK, Schropp KP, Lobe TE. The use of minimal access surgery in pediatric trauma: a preliminary report. J Laparoendosc Surg 1995; 5:295–301. 119. Poletti P, Wintermark M, Schnyder P, Becker CD. Traumatic injuries: role of imaging in the management of the polytrauma victim (conservative expectation). Eur Radiol 2002; 12:969–978. 120. Goffette PP, Laterre PF. Traumatic injuries: imaging and intervention in post-traumatic complications (delayed complications). Eur Radiol 2002; 12:994–1021. 302 Stylianos et al. 19 Pediatric Genitourinary Trauma James R. Colvert Urology Resident, University of Oklahoma, Health Sciences Center, Oklahoma City, Oklahoma, U.S.A. Bradley P. Kropp and Earl Y. Cheng Department of Urology, Children’s Hospital of Oklahoma, University of Oklahoma, Health Sciences Center, Oklahoma City, Oklahoma, U.S.A. INTRODUCTION Trauma is the leading cause of death between the ages of 1 and 44 years, and accounts for almost 50% of deaths in children aged 1 to 14 in the United States (1). Injury to the urinary tract occurs in 3–10% of patients suffering from blunt or pene- trating trauma and is second only to the central nervous system in frequency of childhood injury (2,3). However, death due to genitourinary trauma is uncommon. Although the pediatric urologist is rarely involved in the initial resusc itation of the trauma patient, the trauma surgeon relies heavily upon him to deal with complex injuries to the urological system. The team approach to management provides the highest level of expertise in reducing morbidity and preventing mortality. The majority of clinical practice in pediatric urologic trauma is derived from adult standards. However, the anatomy and physiology of the pediatric patient differ in numerous ways. Management of the pediatric patient should be tailored to reflect these differences. There are several aspects in the evaluation of trauma patients that are unique to the pediatric population, and caution must be exercised in the appli- cation of adult treatment algorithms. Despite these distinct differences, there is a pau- city of literature available that outlines clinical guidelines for children. In this review, we attempt to highlight the pertinent issues in genitourinary trauma in children that allow for a more focused diagnostic approach and appropriate management plan. RENAL TRAUMA The kidney is the most commonl y injured organ in the urogenital system as well as the most commonly injured abdominal organ (4,5). Children appear to be more susceptible to major renal trauma than adults (6). Several unique anatomic aspects contribute to this observation including: less cushioning from perirenal fat, weaker abdominal musculature , and a less well-ossified thoracic cage. The child’s kidney 303 also occupies a proportionall y larger space in the retroperitoneum than does an adult kidney (7). In addition, the pediatric kidney may retain fetal loabulations, permitting easier parenchymal disruption (6). Renal trauma is broadly classified as being blunt or penetrating. Blunt trauma is more common, accounting for greater than 90% of injuries in some series (8). In the pediatric population 14% of blunt abdominal trauma patients have a renal injury (9). Blunt renal injuries are most commonly associated with rapid deceleration forces, automobile accidents, pedestrian–vehicle accident s, falls, contact sports, and personal violence. The kidney, which is relatively mobile within Gerota’s fascia, can be crushed against the ribs or vertebral column, resulting in parenchymal lacera- tions or contusions. Kidney tissue may also be lacerated directly by fractured ribs. Penetrating trauma accounts for 10–20% of renal injuries, yet is responsible for the majority of major renal injuries that require surgery (10). Penetrating trauma from stabbings or gunshot wounds are much less common in children than adults (11). Reviews of firearm injuries show a significant rise in fatalities by firearms in children: homicides rose by 21% and suicides by 30% among those under 16 years between 1968 and 1991 (12). Gunshot wounds produce a radiating wave of injury and cavitation known as ‘‘blast effect,’’ which damages tissues beyond the tract of the projectile. Blast effect may cause delayed tissue necrosis leading to bleeding, urine leak, or abscess from areas that appear viable at the time of surgical explora- tion. Penetrating injuries to the chest, abdomen, flank, and lumbar regions should be assumed to have inflicted renal injury until proven otherwise (13). Pre-existing or congenital renal abnormalities, such as hydronephrosis, tumors, or abnormal position, may predispose the kidney to injury from relatively mild traumatic forces. Historically, congenital abnormalities in injured kidneys have been reported to vary from 1% to 21%. More accurate recent reviews have shown that incidence rates are 1–5% (5,7,14,15). Renal abnormalities, particularly hydro- nephrotic kidneys, may be first diagnosed after minor blunt abdominal trauma (3,16). Most often, these patients present with hematuria following blunt trauma. Others may present with an acute abdomen secondary to intraperitoneal rupture of the hydronephrotic kidney (17). Major deceleration and flexion injuries can lead to renal artery or vein injuries due to stretching forces on a normally fixed vascular pedicle. This type of injury may be more common in children because of their increased flexibility and renal mobility (18,19). Post-traumatic thrombosis of the renal artery occurs secondary to an intimal tear. The intimal layer tears from the wall of the vessel because the media and adventitia of the renal artery are more elastic than the intima (20). The intimal tear pro- duces turbulence, thrombosis, and eventual occlusion that then results in renal ischemia. A high index of suspicion must be maintained in order to identify these injuries (21). Diagnosis Blunt Trauma Once the patient has been resuscitated and life-threatening injuries have been addressed, evaluation of the genitourinary system can be undertaken. Following any blunt injury, the presence of hematuria (microscopic or gross), palpable flan k mass, or flank hematomas are obvious indications for urologic evaluations. Most major blunt renal injuries occur in association with other major injuries of the head, chest, and abdomen. Urologic investigations should be undertaken when trauma to the lower chest is associated with rib, thoracic, or lumbar spine fractures. It should 304 Colvert et al. also be undertaken in all crush injuries to the abdomen or pelvis when the patient has sustained a severe deceleration injury. Since a renal pedicle injury or ureteropelvi c junction disruption may not be associated with one of the classic signs of renal injury, such as hematuria, radiological evaluation of the urinary tract should always be considered in patients with a mechanism of injury that could potentially injure the upper urinary tract. Gross hematuria, the most reliable indicator for serious urological injury, mandates radiographic evaluation (22,23), The need for imaging in the patient with microscopic hematuria is not as clear cut. One must remember that the degree of hematuria does not always correlate with the degree of injury (24). Renal vascular pedicle avulsion or acute thrombosis of segmental arteries can occur in the absence of hematuria while mild renal contusions can present with gross hematuria (25). It is well documented in the adult literature that the vast majority of patients suffering from blunt trauma with microscopic hematuria and no evidence of shock (SBP < 90 mmHg) have minor renal injuries and do not need to be studied radiographically (25–28). Guidelines for evaluating the pediatric population are not as clearly defined. Due to the catecholamine response to trauma, children are able to maintain a normal blood pressure despite a significant loss of volume (24). Unlike adult patients, hypo- tension does not appear to be a reliable indicator of the severity of renal injury in children and diagnostic evaluation should not be reserved only for those in shock (23). Thus, all children with any degree of microscopic hematuria after blunt trauma have traditionally undergone renal imaging (15). Recently Morey et al. in a meta - analysis of all reported series of children with hematuria and suspected renal injur y noted that only 2% (11 of 548) of patients with insignificant microscopic hematuria (<50 RBC/HPF) had a significant renal injury (29). However, it is important to note that all 11 of these patients were found to have multiple organ trauma so that renal imaging would have been performed in the course of evaluation despite the relatively minor amount of microscopic hematuria. Detection of significant renal injury was found to increase to 8% with significant microhematuria (> 50 RBC/HPF), and 32% in those with gross hematuria after blunt trauma. The presence of multi-system trauma significantly increa ses the risk for significant renal damage (23). They concluded that it is reasonable to consider observation with no renal imag ing in chil- dren with microscopic hematuria of <50 RBC/HPF that are stable and without a mechanism of injury that is suspect for renal injury (29). Historically, intravenous pyelography (IVP) has been the radiographic imaging study of choice in determining the presence and extent of renal injury. Sensitivity has been reported as high as 90% in diagnosing renal injury (13). Unfortunately, IVP misses other intra-abdominal injuries and has been shown to miss or understage renal injury in children by 50% in comparison to computed tomography (CT), Several stu- dies now indicate that conventional IVP has an extremely low yield and rarely alters management in pediatric patients with blunt renal trauma, especially in patie nts with isolated microhematuria (5,30–32). However, intravenous pyelography still serves an important role in all penetrating renal and hemodynamically unstable blunt renal trauma patients who require immediate surgical exploration without preoperative imaging (25). A one-shot trauma IVP can be performed in the operative setting and consists of 2–3 mL/kg of non-ionic contrast injected intravenously, followed by a single abdominal radiograph 10 minutes later. The purpose of the IVP is to determine the presence of two functioning renal units, urinary extravastion, and renal parenchymal injury (13,33). With an intra-operative one-shot IVP the need for renal exploration has been obviated in 32% of patients (34). Pediatric Genitourinary Trauma 305 CT scans are now used almost exclusively as the imaging study of choice for suspected renal trauma in hemodynamically stable adults and children (29,35). The CT imaging is both sensitive and specific for demonstrating parenchymal laceration, urinary extravasation, delineating segmental parenchymal infarcts, determining the size and location of the surrounding retroperitoneal hematoma, and/or associated intra-abdominal injury (36,37). The CT scans allow for accurate staging of the renal injury, which has important management implications which will be discussed later. With the advent of CT, evaluation of renal trauma has now become much more precise. Several classification systems of renal trauma that are in part based on CT scan findings have been described. The most commonly used staging system is from the American Association for the Surgery of Trauma (Table 1) that divides renal trauma into five grades that have predictive value in the subsequent management strategy of these injuries: grade I renal contusion or nonexpanding subcapsular hematoma with- out a renal parenchymal laceration; grade II non-expanding perirenal hematoma or a renal cortex laceration ( < l cm) without urinary extravasation; grade III renal cortex laceration ( > l cm) and no urinary extravasation; grade IV renal cortical laceration extending into the collecting system (as noted by contrast extravasation), or a segmen- tal renal artery or vein injury (noted by segmental parenchymal infarct), or main renal artery or vein injury with a contained hematoma; grade V shattered kidney, avulsion of the renal pedicle, or thrombosis of the main renal artery (Fig. 1) (38). The ultimate goal of complete staging is to provide sufficient information for management that results in the preservation of renal parenchyma and the salvage of injured kidneys (Fig. 2). Ultrasonography also has bee n used to assess renal trauma. However, its sensi- tivity in demonstrating renal injury in comparison to CT is only 25–70%. It may also miss associated intra-abdominal injuries (5,39). Recently, focused abdominal sono- graphy for trauma (FAST) has become increasingly popular as a screening test for patients with suspected intra-abdominal injury. Nevertheless, FAST has been shown to have a low sensitivity for solid organ injury in children. It also provides poor infor- mation concerning renal function or pedicle injuries. Thus, renal ultrasound, at present, is not currently recommended as a useful screening tool for urologic evalua- tion in the setting of blunt renal traum a (40). Table 1 American Association for the Surgery of Trauma Organ Injury Severity Score for the Kidney Grade a Type Description I Contusion Microscopic or gross hematuria, urologic studies normal Hematoma Subcapsular, nonexpanding without parenchymal laceration II Hematoma Nonexpanding perirenal hematoma confined by Gerota’s fascia Laceration <1.0 cm parenchymal depth of renal cortex without urinary extravasation III Laceration >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation IV Laceration Parenchymal laceration extending through renal cortex, medulla, and collecting system Vasscular Main renal artery or vein injury with contained hemorrhage V Laceration Completely shattered kidney Vascular Avulsion of renal hilum that devascularizes kidney a Advance one grade for bilateral injuries up to grade III. 306 Colvert et al. It is always important to remember that major renal injuries such as ureteropelvic junction (UPJ) disruption or segmental arterial thrombosis may occur without the presence of hematuria or hypotension. Therefore, a high index of suspi- cion is necessary to diagnose these injuries. Non-visualization of the injured kidney on IVP, or failure to uptake contrast with a large associated perirenal hematoma on CT are hallmark findings for renal artery thrombosis. UPJ disruption is classically seen as perihilar extravasation of contrast with nonvisualization of the dist al ureter (20,23,29,41). Penetrating Trauma Renal injury due to penetrating trauma should be suspected with entrance wounds in the lower thorax, flank area, or upper abdomen. These injuries tend to be more severe and more unpredictable than injuries due to blunt trauma. Hematuria, usually gross, commonly accompanies major parenchymal lacerations. However, renal pedicle injuries may occur as an isolated laceration without producing hematuria. Renal imaging is therefore indicated in any patient with any degree of hematuria associated with penetrating trauma. As with blunt trauma, abdominal CT is the imaging study of choice for patients with suspected renal trauma from a penetra- ting injury. Selected patients, that are accurately staged, with minor renal injuries may be considered for non-operative management (42,43). In unstable patients requiring immediate resuscitation and laparotomy, an intra-operative single-shot Figure 1 American Association for the Surgery of Trauma Organ Injury Severity Score for the kidney. Source: From Ref. 96. Pediatric Genitourinary Trauma 307 [...]... trauma J Trauma 1 985 ; 25(7): 587 –593 5 McAleer IM, Kaplan GW, Scherz HC, Packer MG, Lynch FP Genitourinary trauma in the pediatric patient Urology 1993; 42(5):56 3-5 67; discussion 567–5 68 6 Brown SL, Elder JS, Spirnak JP Are pediatric patients more susceptible to major renal injury from blunt trauma? A comparative study J Urol 19 98; 160(1):1 38 140 7 Cass AS Blunt renal trauma in children J Trauma 1 983 ;... adults? Z Kinderchir 1 988 ; 43(1):31–34 15 Abou-Jaoude WA, Sugarman JM, Fallat ME, Casale AJ Indicators of genitourinary tract injury or anomaly in cases of pediatric blunt trauma J Pediatr Surg 1996; 31(1): 86 89 ;discussion 90 Pediatric Genitourinary Trauma 321 16 Brower P, Paul J, Brosman SA Urinary tract abnormalities presenting as a result of blunt abdominal trauma J Trauma 19 78; 18( 10):719–722 17 Ekwueme... kidney Br J Surg 1976; 63 (8) :637–6 38 18 Smith EM, Elder JS, Spirnak JP Major blunt renal trauma in the pediatric population: is a nonoperative approach indicated? J Urol 1993; 149(3):546–5 48 19 McAleer IM, Kaplan GW Pediatric genitourinary trauma Urol Clin North Am 1995; 22(1):177– 188 20 Haas CA, Spirnak JP Traumatic renal artery occlusion: a review of the literature Tech Urol 19 98; 4(1):1–11 21 Smith... in pediatric blunt abdominal trauma decreasing the delay from injury to treatment J Trauma 1993; 35(6) :86 1 86 4 22 Pollack HM, Wein AJ Imaging of renal trauma Radiology 1 989 ; 172(2):297–3 08 23 Quinlan DM, Gearhart JP Blunt renal trauma in childhood Features indicating severe injury Br J Urol 1990; 66(5):526–531 24 Stein JP, Kaji DM, Eastham J, Freeman JA, Esrig D, Hardy BE Blunt renal trauma in the pediatric. .. renal trauma Can J Surg 1993; 36(1):59–62 32 Lieu TA, et al Hematuria and clinical findings as indications for intravenous pyelography in pediatric blunt renal trauma Pediatrics 1 988 ; 82 (2):216–222 33 Morey AF, et al Single shot intraoperative excretory urography for the immediate evaluation of renal trauma J Urol 1999; 161(4):1 088 –1092 34 Santucci RA, McAninch JW Diagnosis and management of renal trauma; ... renal trauma Urol Clin North Am 1 989 ; 16(2): 187 –192 29 Morey AF, Bruce JE, McAninch JW Efficacy of radiographic imaging in pediatric blunt renal trauma J Urol 1996; 156(6):2014–20 18 30 Hashmi A, Klassen T Correlation between urinalysis and intravenous pyelography in pediatric abdominal trauma J Emer Med 1995; 13(2):255–2 58 31 Middlebrook PF, Schillinger JF Hematuria and intravenous pyelography in pediatric. .. 11(3):2 18 220 80 Boone TB, Wilson WT, Husmann DA Postpubertal genitourinary function following posterior urethral disruptions in children J Urol 1992; 1 48( 4):1232–1234 81 Morehouse DD, Belitsky P, Mackinnon K Rupture of the posterior urethra J Urol 1972; 107(2):255–2 58 82 Marshall FF, Chang R, Gearhart JP Endoscopic reconstruction of traumatic membranous urethral transection J Urol 1 987 ; 1 38( 2):306–309 83 ... 143(4): 682 – 684 56 Wessells H, McAninch JW Effect of colon injury on the management of simultaneous renal trauma J Urol 1996; 155(6): 185 2– 185 6 57 McAninch JW, Carroll PR, Klosterman PW, Dixon CM, Greenblatt MN Renal reconstruction after injury J Urol 1991; 145(5):932–937 58 Carroll PR, Klosterman P, McAninch JW Early vascular control for renal trauma: a critical review J Urol 1 989 ; 141(4) :82 6 82 9 59 Howerton... the traumatized posterior urethra J Urol 1992; 1 48( 5):14 28 1431 84 Spirnak JP, Smith EM, Elder JS Posterior urethral obliteration treated by endoscopic reconstitution, internal urethrotomy and temporary self-dilation J Urol 1993; 149(4): 766–7 68 85 Patterson DE, Barnett DM, Myers RP, DeWeerd JH, Hall BB, Benson RC Jr Primary realignment of posterior urethral injuries J Urol 1 983 ; 129(3):513–516 86 White... alternatives J Urol 1997; 157(4): 1444–14 48 90 Kardar AH, Sundin T, Ahmed S Delayed management of posterior urethral disruption in children Br J Urol 1995; 75(4):543–547 324 Colvert et al 91 Altarac S Management of 53 cases of testicular trauma Eur Urol 1994; 25(2):119–123 92 Bertini JE, Corriere JN The etiology and management of genital injuries J Trauma 1 988 ; 28( 8):12 78 1 281 93 Cass AS, Luxenberg M Value . manage- ment of duodenal injuries in children. J Pediatric Surg 1997; 32 :88 0 88 6. Abdominal Trauma in Children 299 68. Winthrop AL, Wesson DE, Filler RM. Traumatic douodenal hematoma in the pediatric patient patients. J Trauma 2000; 48: 201–207. 52. Cogbill TH, Moore EE, Jurkovich GJ. Severe hepatic trauma: a multicenter experience with 1,335 liver injuries. J Trauma 1 988 ; 28: 1433–14 38. 53. Hirshberg. genital trauma: accidental and nonaccidental injuries. Pediatr Emerg Care 19 98; 14:95– 98. 107. Reinberg O, Yazbeck S. Major Perineal trauma in children. J Pediatr Surg 1 989 ; 24: 982 – 984 . 1 08. Orr