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West Virginia Pediatric Renal Trauma: A Level One Trauma Center Experience.

Introduction

Trauma is the single greatest cause of morbidity and mortality in pediatric patients throughout the world. (1) In theory, the kidneys are more susceptible to trauma in pediatric patients when compared to adult patients secondary to lower amounts of perirenal fat, relatively larger size, and decreased protective coverage via the thoracic cavity. (2) The majority of renal traumas experienced by pediatric populations is conducted via blunt force, is of low grade, and occurs more commonly in children who are at least five years of age. (3) Common mechanisms of renal injury, excluding nonaccidental trauma, include blunt trauma by way of recreational vehicles, motor vehicle accidents, sports-related injuries, and falls.

In pediatric patients with renal injuries, non-operative management is the preferred course of treatment for all grades in the setting of stable patients who have suffered blunt trauma. (4) This is due in part to the unique physiology of the pediatric patient having smaller diameter blood vessels and an enhanced vasoconstrictive response as compared to the same response in adults. (5) Conservative management is also preferred in stable patients as it results in shorter hospitalization periods, decreased need for blood transfusions, and lower morbidity and mortality when compared to operative management. (6) As demonstrated by Grimsby et al., even though the majority of pediatric patients who experience blunt abdominal trauma are managed conservatively, the rate of nephrectomy is up to three times higher when this population is treated at institutions focused on adult medicine as opposed to pediatric centers. (3) Therefore, a heightened evaluation of the handling of pediatric renal trauma is warranted.

In the evaluation of trauma, a majority of patients undergo a focused assessment with sonography for trauma (FAST) exam or CT scan to evaluate for intra-abdominal bleeding and/or solid organ injury. Urinalysis is also commonly performed to evaluate for microscopic hematuria. The American Urologic Association (AUA) recommends a CT IVP for any pediatric patients with blunt trauma and gross hematuria, blunt trauma with microscopic hematuria (=50 RBCs/hpf) and systemic shock (systolic BP <90 mmHg), significant deceleration or high velocity accident, trauma resulting in fracture of thoracic rib cage, spine, pelvis, or femur, and all penetrating flank trauma. (7, 8) Importantly, pediatric patients are less likely to present with hypotension due to their sympathetic tone being able to keep a normal blood pressure despite significant blood loss. (8) The aim of our study was to evaluate the characteristics and mechanisms of injury of pediatric patients presenting to our trauma center with renal injuries. Additionally, this study evaluated the sensitivity of different imaging modalities commonly used in the trauma workup and the management of qualifying patients.

Methods In this institutionally approved IRB study, we performed a retrospective analysis of the pediatric patients (under the age of 18) presenting to West Virginia University Hospital who had suffered renal trauma as confirmed by CT imaging from July 2009 to January 2014. Initial evaluation followed the ATLS guidelines for pediatric trauma, which included physical examination by the trauma and emergency medicine services, laboratory tests (CBC, BMP, PT/INR, PTT, serum toxicology screen, and urinalysis), and diagnostic imaging (FAST and/or CT scan). Microscopic hematuria was defined as =50 RBCs/hpf. Classifications of renal injury grade were made based on the American Association for the Surgery of Trauma. All patients with at least a grade III injury had delayed imaging on initial CT scan or repeat CT IVP within 48 hours to evaluate for urinary extravasation. All patients followed the renal trauma treatment guidelines, based on their degree of renal injuries, established by the urology and trauma services at West Virginia University (Table 1). Our patients were followed in our prospectively maintained database on the WVU trauma registry. Parameters analyzed included the mechanism of injury, presence of hematuria, degree of injury, management, and follow-up. Additionally, we reviewed the use and efficacy of the FAST exam for pediatric renal trauma.

Results

Twenty-one pediatric patients were identified as having sustained traumatic renal injuries from July 2009 to January 2014. All injuries were sustained via blunt trauma with none occurring due to penetrating injury. Thirteen of the patients (61.9%) were male and 9 patients were female (38.1%). Ages ranged from 6-17 years old (median 15 years) with the majority being =13 years old (85.7%). All patients were evaluated via CT imaging studies and 17 were also evaluated via bedside FAST on presentation.

Renal injury was classified as grade I in 7 (30.4%) renal injuries, grade II in 4 (17.4%), grade III in 6 (26.1%), grade IV in 5 (21.7%) and grade V in 1 (4.3%) patient

Of the 17 patients who underwent FAST exams -10 were positive for renal injury or free fluid in the abdomen (58.8%). The most common mechanisms of injury were the result of recreation vehicle accidents including all-terrain vehicles (ATVs), boats, and dirt bikes--(28.6%). This group was also associated with the highest average grade of renal injury (3.3). None of these patients were wearing safety equipment. Sportsrelated injuries, specifically skiing and football, were the second most common mechanism of traumatic injury, accounting for 23.8% and were associated with the second highest average grade of renal injury (2.8). Finally, 4 patients each sustained renal injury from MVCs (23. 8%) and falls (19.0%) with each being associated with an average grade renal injury of 2.25 (Table 3).

One patient observed was incidentally found to have an ureteropelvic junction (UPJ) obstruction. Of the 21 patients involved, 10 (47.6%) suffered poly trauma - with splenic injury being the most pervasive additional solid organ injury. One patient expired shortly after presentation to the ED due to multi-system trauma following a logging accident and another died from a multi-system injury from a MVC. Two of the patients with grade IV injuries also had a grade 1 contralateral renal injury. Endoscopic intervention with ureteral stent placement was performed in 1 of the 5 grade IV injuries. The ureteral stent was removed in clinic after a CT IVP showed no urinary extravasation at 8 weeks from the initial injury. The single grade V renal injury was a renal avulsion from a boating accident that required intravascular embolization performed by interventional radiology. He was the only patient with only a renal laceration who required a blood transfusion. Three patients with more severe injuries to other solid organs also received blood transfusions. None of the 21 patients required nephrectomy or renal exploration. Thus, the rate of endoscopic intervention was 4.3%, endovascular embolization 4.3%, and nephrectomy 0%. Patients were followed-up in clinic based on the guidelines from Table 1, with no patients requiring additional intervention or follow-up after this visit.

With regards to hematuria, 57.1% of the patients presented with gross hematuria, 19.0% presented with microscopic hematuria, and 19.0% had no hematuria. Regarding the relationship between severity of the injury and incidence of hematuria: 62. 5% of grade I-II, 83.3% of grade III, and 33.3% of grade IV-V injuries presented with gross hematuria while 12.5% of grade I-II, 16.7% of grade III, and 33.3% of grade IV-V injuries presented with microscopic hematuria. Of note, all patients with a grade III injury presented with hematuria while 25% grade I-II and 33. 3% of grade IV-V did not present with hematuria of any kind (Table 4).

Discussion

Renal injury is a common finding in pediatric patients suffering blunt abdominal injuries occurring in 10-20% patients. (2,9) In all pediatric traumas, renal injuries are found in up to 3% patients. (2,9) This study elucidates many commonalities between pediatric renal trauma cases at WVU and similar cases on a national level. At our institution, the average age of pediatric renal trauma patients was ~14 years. This is comparable to the national average of 13.7 years reported by the National Trauma Database. (10) We also found the distribution of grades of renal injury to be consistent with those reported by Dangle et al. Who conducted a similar study investigating pediatric trauma patients in Pennsylvania. Our percentages were 30.4, 17.4, 26.1, 21.7, and 4.3 for grades I-V, respectively. In comparison, percentages reported by Dangle et al. For grades I-V were 25.4, 19.3, 25.9, 24.6, and 4.8, respectively. The most common mechanisms of renal trauma at WVU were due to recreational vehicles (ATVs, motorcycles, boats), followed by motor vehicles and sports, which was similar to previous studies. (10) Despite the similarities in mechanisms of injury, pediatric renal trauma due to recreational vehicles at our institution resulted in a higher grade on average (3.3) than those in Pennsylvania (2.6). (10)

ATV-related injuries are on the rise and are of particular concern in the state of West Virginia.

From 2000 to 2006, our institution observed a 325% increase in the number of ATV-related injuries. Of these injuries, 22% were found in patients age 16 years and under. (11) Similarly, a level 1 trauma center in Charleston, WV found that the incidence of ATV-related death in children doubled from 1998 to 2011. (12) In 2012, West Virginia was found to have the second highest rate of ATV-related injuries (1.63 per 100,000 population) in the United States, trailing only Alaska. (13)

Pediatric renal injuries often present with concomitant injuries to other solid organs. Lacerations of the spleen and liver are the most common additional findings. In our study, 47.6% of patients suffered poly trauma, with splenic injury being the most common associated injury (33%). This is supported by the findings of Kluemper et al., who observed a splenic injury rate of 31% in pediatric patients presenting with genitourinary injury. (9) Three patients in this study required blood products and one patient required interventional radiology guided splenic artery embolization. All four patients experienced trauma from a vehicular accident--two from MVCs, one from a dirt bike accident, and one from a boating accident.

Prompt detection of renal injuries is critical to management and subsequent clinical outcomes. Based on the patient population at our institution, identifying renal injuries requires a high index of suspicion of hematuria, whether microscopic or gross and does not predictably correlate with the degree of injury. Our series illustrated this pattern as only 76.2% of patients presenting with renal lacerations exhibited hematuria with 57.1% exhibiting gross hematuria and another 19.0% exhibiting microscopic hematuria. The remaining 19.0% did not present with hematuria. This is in contrast to the findings of Hale et al. Whose results indicated that 100% of patients (N=10) presented with hematuria, four of which illustrated gross hematuria. (12) Also, in cohort high grade renal injuries (IV and V) were less likely to have gross hematuria (33.3%) than low grade injuries (82.3%). This further indicates the need to complete a trauma work-up based on the mechanism of injury, like significant deceleration, and not just based on the presence of hematuria.

Management of renal injuries at our institution was similar to other studies. Dangle et al. Found in the last 20 years only 2.4% of renal injuries required endoscopic intervention and 1.2% required nephrectomy at their institution. (10) In the National Trauma Registry from 2011-2012 only 0.08% of renal injuries required endovascular intervention and 0.07% required nephrectomy in 1557 blunt pediatric renal injuries recorded. (14) At our institution endovascular embolization is indicated in patients who are stable with arterial extravasation, an expanding hematoma, or dropping hemoglobin not responding to blood transfusions. Other solid organs, like the liver and spleen, have similar rates of needing embolization. (14) The adverse effects of renal embolization are not well studied, but it does not appear to have a significant risk for hypertension. (15, 16). Thus, arterial embolization offers a safe alternative to nephrectomy. Although some clinicians may delay ambulation until resolution of hematuria, we do not, as there was no correlation between rate of hematuria and grade of injury. Additionally, no patients suffered complications or deep vein thrombosis due to starting DVT prophylaxis too early or late, respectively.

Two patients in the cohort were readmitted after discharge; one due to tachycardia believed to be SVT or torsades de pointes, and the other for pancreatitis, which developed into a pseudocyst. No patients were readmitted due to complications from renal injuries.

Additionally, many hospitals utilize the FAST exam as a modality for rapid initial evaluation of abdominal injury. Of the patients evaluated in this study, 80% underwent FAST exam upon arrival to the ED and 59% of them were found to be positive for renal injury or free fluid in the abdomen. This sensitivity correlates well with the findings of Ben-Ishay et al. Who calculated a similar sensitivity of approximately 50% for such cases. (17) In comparison, ultrasound has been shown to harbor sensitivity as high as 91% for renal injury--the remaining 9% were determined by CT scan to be grade I injuries. (4) It should be noted that the sensitivity of ultrasound for detecting renal trauma is largely dependent on the skill of the user. Despite this characteristic, ultrasound remains a valuable asset in the evaluation of the trauma patient.

Conclusions

In our tertiary referral trauma center, the most common form of pediatric renal trauma was blunt trauma, with the most common mechanism being from recreational vehicle accidents. Recreational vehicle accidents resulted in the highest grade of renal trauma, as well. The majority of pediatric blunt renal trauma injuries can be managed conservatively without the need for surgical intervention. Interestingly, high grade renal lacerations were less likely to present with gross hematuria than low grade renal injuries.

References

(1.) Bhatti KM, Taqi KM, Al-Harthy AZ, et al. Paediatric Blunt Torso Trauma: Injury mechanisms, patterns and outcomes among children requiring hospitalisation at the Sultan Qaboos University Hospital, Oman. Sultan Qaboos University medical journal. May 2016;16(2):e210-216.

(2.) Levy JB, Baskin LS, Ewalt DH, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. Oct 1993;42(4):418-424.

(3.) Grimsby GM, Voelzke B, Hotaling J, Sorensen MD, Koyle M, Jacobs MA. Demographics of pediatric renal trauma. The Journal of urology. Nov 2014;192(5):1498-1502.

(4.) He B, Lin T, Wei G, He D, Li X. Management of blunt renal trauma: an experience in 84 children. International urology and nephrology. Dec 2011;43(4):937-942.

(5.) Miele V, Piccolo CL, Trinci M, Galluzzo M, Ianniello S, Brunese L. Diagnostic imaging of blunt abdominal trauma in pediatric patients. La Radiologia medica. May 2016;121(5):409-430.

(6.) Guzel M, Arslan S, Turan C, Doganay S. Management of renal injury in children. Annali italiani di chirurgia. May-Jun 2015;86(3):246-251.

(7.) Morey AF, Brandes S, Dugi DD, 3rd, et al. Urotrauma: AUA guideline. The Journal of urology. Aug 2014;192(2):327-335.

(8.) Wein AJ, Kavoussi LR, Campbell MF. Campbell-Walsh urology / editor-in-chief, Alan J. Wein ; [editors, Louis R. Kavoussi... et al.]. 10th ed. Philadelphia, PA: Elsevier Saunders; 2012.

(9.) Kluemper C, Rogers A, Fallat M, Bernard AC. Genitourinary injuries in pediatric all-terrain vehicle trauma--a mechanistic relationship? Urology. May 2010;75(5):1162-1164.

(10.) Dangle PP, Fuller TW, Gaines B, et al. Evolving Mechanisms of Injury and Management of Pediatric Blunt Renal Trauma--20 Years of Experience. Urology. Apr 2016;90:159-163.

(11.) Dietz MJ, Lavender C, Emery SE, Clovis N, Shuler FD, Zuberi J. All-terrain vehicle-related orthopaedic trauma in North Central West Virginia: an 8-year review of a Level I trauma center. Journal of orthopaedic trauma. Jul 2012;26(7):e83-87.

(12.) Hale N, Brown A. Mechanistic relationship of all-terrain vehicles and pediatric renal trauma. Urology. Jan 2013;81(1):160-162.

(13.) Helmkamp JC, Aitken ME, Graham J, Campbell CR. State-specific ATV-related fatality rates: an update in the new millennium. Public health reports. Jul-Aug 2012;127(4):364-374.

(14.) Safavi A, Skarsgard ED, Rhee P, et al. Trauma center variation in the management of pediatric patients with blunt abdominal solid organ injury: a national trauma data bank analysis. Journal of pediatric surgery. Mar 2016;51(3):499-502.

(15.) Capozza N, Collura G, Falappa P, Caione P. Renal embolization as an alternative to surgical nephrectomy in children. Transplantation proceedings. Jul-Aug 2007;39(6):1782-1784.

(16.) Kiankhooy A, Sartorelli KH, Vane DW, Bhave AD. Angiographic embolization is safe and effective therapy for blunt abdominal solid organ injury in children. The Journal of trauma. Mar 2010;68(3):526-531.

(17.) Ben-Ishay O, Daoud M, Peled Z, Brauner E, Bahouth H, Kluger Y. Focused abdominal sonography for trauma in the clinical evaluation of children with blunt abdominal trauma. World journal of emergency surgery : WJES. 2015;10:27.

Daniel McClelland, BS James Scheidler II, BS Dana Point, MD Chad Morley, MD Adam Luchey, MD, And Osama AL-Omar, MD

Department of Surgery, Division of Urology, West Virginia University Robert C. Byrd Sciences Center, Morgantown, WV, USA

Corresponding Author: Chad Morley, MD, Chief Resident Urology, Dept. of Surgery, Div. Of Urology, WVU Robert C. Byrd Sciences Center, P.O. Box 9238, Morgantown, West Virginia 2650-9238. Email: cmorley1@hsc.wvu.edu.
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Author:McClelland, Daniel; Scheidler, James, II; Point, Dana; Morley, Chad; Luchey, Adam; AL-Omar, Osama
Publication:West Virginia Medical Journal
Article Type:Report
Geographic Code:1U5WV
Date:Jan 1, 2018
Words:2841
Previous Article:West Virginia Bureau For Public Health News.
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