Foundation Year 2 Basingstoke amp North Hampshire Hospital Thanks to Mr Govindaraj Rajkumar Paediatric renal trauma Case Study Long term complications Case Study BS 14yo boy PMHx constipation age 612 mild asthma ID: 1031960
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1. Paediatric renal traumaJames Austin Foundation Year 2Basingstoke & North Hampshire Hospital
2. Thanks to Mr Govindaraj Rajkumar
3. Paediatric renal traumaCase Study Long term complications
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5. Case Study
6. BS 14yo boyPMHx – constipation (age 6/12), mild asthmaDHx - nil
7. BS 14yo boyWent up half pipe ramp on scooterFront wheel landed on top of ramp and fell overUnable to recall precise mechanism of landingReturned home
8. BS At homePassed urine – blood seen!Right sided abdo pain – worse if walk
9. BS On arrival by ED consultantRR 18, Sp 100%, BP 112/67, HR 86AlertTender right flankNo guarding/peritonismBlood on urethral meatusReferred to surgeons
10. Features suggestive of significant renal traumaThere are no consistent features seen in all renal traumaMechanism can be relatively innocuousGross haematuria can occur with simple small haematomasTherefore, low threshold to suspect!
11. BS On call surgeons r/vBloods + venous gasIVIUrinary catheterBed restITU r/v and on call urology contactNo urology contact for 3hrs!!
12. BS Paediatrician, Urologist, ITU consultant and Surgical on call plan agreed30 minute observations4hrly venous gas for Hb and lactateTranexamic acidIVABx Transfuse Hb <90g/dlLiaise with paediatric surgeons (UHS)
13. BS Assessment overnightHb 133->121->118->122Lactate remains 1.0-1.6mmol/LCatheter drain dark urine with washoutPassing 62.5ml/hr (1.1ml/kg/hr)Codeine/paracetamol improves painCreatinine 71
14. BS Morning review (urology)Clear urineHb 118-> 113Urine 60ml/hrSoft abdomen and not tenderHR 91, BP 98/55, Sp 99% on airUSS arranged Creatinine 71-> 67
15. USS KUB – perinephric haematoma of right kidney with possible small lacerationCT KUB is organised
16. CT KUB – comminuted fracture of waist of right kidney extending to lower pole and pelvicalyceal systemGrade IV injury
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18. AAST gradingGrades 1-5 – increasing severity Higher grades -> more likely surgical intervention
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20. Day 3-4 Temp 37.5-37.9’C, HR 100-110Cultures takenHb 108, WCC 15.1, CRP 54on IV ceftriaxoneMicrobiology -> add metronidazole, ?infected haematomaCT angiogram performed
21. CT angiogram - no extravasation But note contrast entering perinephric haematoma -> suggest communication with the urinary systemGeneralised fluid in the abdomen -> ?pneumoperitoneum
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24. Day 5Cystoscopy and right ureteric stent placed
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26. Day 6-8Continuing feversCultures negative, CRP 110, Hb 108But feels wellDischarged with oral amoxicillin and repeat USS KUBSuggested that fevers-> resolving haematoma
27. Post discharge 2/52 – repeat USS shows resolving collection3/52 – stent removed4/52 – new abdo pain, seen by urology but resolves5/52 – DNA to OPA
28. Post discharge 3/12 – OP clinic -> occasional pain but well, Hb 145, Creatinine 576/12 – USS – fully resorbed haematoma, irregular contour suggesting cortical scarring7/12 – OP clinic -> DNA -> discharged from urology with no further follow up.
29. Complications of renal trauma
30. Paediatric anatomyKidneys lower in abdomenflayed rib cageLess perinephric fat/supportthinner blood vessels thinner abdominal musculature -> more prone to deceleration injury , falls etc
31. Acute complicationsUrinomaHaematomaRetroperitoneal haemorrhageSepsisPerinephric abscess PseudoaneurysmArteriovenous fistulaAcute kidney injuryDevitalised renal segment
32. Long term complicationsRelatively little information availableEven less for paediatrics!
33. Post-trauma hypertensionSuggested 0-33% (average 5.2%) of patientsOccurs 37days – decades (average 34mths)Linked SeverityRenal artery occlusionGrade 4/5 and vascular injuries -> advise BP check for years
34. Page kidney -> HTN secondary to compression renal parenchyma Dogs and cellophane
35. Haematoma/fibrosis -> local ischaemia -> upregulated renin-angiotensin system -> HTNLink to arteriovenous fistula/pseudoaneurysm/ devitalised tissueTreat Anti-hypertensivesstent/angioplasty/embolisation Segment excision OR nephrectomy
36. Arteriovenous fistula70% resolvePenetrating traumaOngoing haematuriaDetect on renal scintigraphy80% can have angiographic embolisation
37. Renal insufficiencyUnclear if a link, one studies report 6.4-16% with reduced function DMSA renal scan -> 17 children at 2yrs, see 21%-55% residual function but normal BP/U&EsLinked to severity of traumaKeller MS, Eric Coln C, Garza JJ, Sartorelli KH, Christine Green
38. Renal calculusScarring or deformity of pelvicalyceal systemAllows a nidus for calculi formationChronic pyelonephritisHydronephrosis
39. OutlookThere is irreversible loss of function following traumaHigher risk of chronic kidney disease in adulthood?Higher risk of future hypertension?No consensus on how to follow up patients – case by case