Pediatric Trauma - Hennepin County Medical Center

Case Reports
Grade
Injury Description
I
II
III
IV
V
Hematoma
Laceration
Hematoma
Laceration
Laceration
Laceration
Hematoma
Laceration
Contusion with microscopic hematuria, urologic studies normal
Non-expanding subcapsular hematoma without parenchymal laceration
Non-expanding peri-renal hematoma confined to renal retroperitoneum
< 1.0 cm parenchymal depth of renal cortex without urinary extravasation
Laceration > 1.0 cm parenchymal depth of renal cortex without collecting system
rupture or urinary extravasation
Parenchymal laceration extending through renal cortex, medulla, and collecting
system with urinary extravasation; injury to main renal artery or vein with
contained hemorrhage
Massive disruption of the duodenopancreatic complex
Devascularization of the duodenum
Table One.
Organ Injury
Scale American
Association for
the Surgery of
Trauma: Kidney 3
With these findings, a left nephrectomy was
performed. Given the proximity of the small bowel
and duodenal injury, a partial duodenectomy and
small bowel resection were performed to include the
distal portion of the third portion of the duodenum, the
fourth portion of the duodenum, and the involved
small bowel. This was reconstructed by mobilizing the
remaining third portion of the duodenum and then
creation of a small bowel to duodenal anastomosis
with a partially stapled, partially hand-sewn technique.
An incidental appendectomy was also performed.
The retroperitoneum continued to have a small but
steady amount of bleeding. This was packed. A
temporary abdominal closure was then performed
with a planned second-look laparotomy in 36 hours.
The patient was then transferred to the PICU.
With the assistance of the pediatric intensivists, the
patient received ongoing fluid resuscitation. Postoperatively,
he remained intubated and sedated. The
patient was taken back to the OR on post-operative
day two. The transverse colon serosal tear was
primarily repaired. The bleeding from the retroperitoneum
had stopped. The duodenal small bowel anastomosis
was inspected and found to be intact and well perfused.
His abdomen was definitively closed. His NG tube
was left in place. He was transferred back to the
PICU and was extubated later that day.
This patient did well postoperatively. His nasogastric
tube was removed on hospital day seven. On hospital
day eight, the nasogastric tube was replaced after an
episode of bilious emesis. A CT scan with PO and IV
contrast was obtained. This showed no leak, but
some edema in the third portion of the duodenum, as
well as a fluid collection within the left renal fossa.
The nasogastric tube was removed on hospital day
11. The patient was discharged to home on hospital
day 16. His peak creatinine during his hospital stay
was 0.9.
Discussion
Renal Injury
Nephrectomy for trauma in children is a rare event;
even in high grade injuries. 1 Indications for nephrectomy
include hemodynamic instability despite fluid resuscitation
from ongoing hemorrhage and uncontrolled sepsis.
Nephrectomy for an ischemic kidney from renal artery
thrombosis is recommended if a laparotomy is being
performed for another reason, i.e. hemorrhage,
suspected bowel injury, etc. Childrenʼs National
Medical Center reviewed its experience with blunt
renal injury in children. 2 This was a single center
retrospective review that included 126 children. Sixty
percent of the patients had a low-grade injury, defined
as American Association for Surgery in Trauma
(AAST) Grade 1, 2, or 3 level of injury. The remaining
40% suffered an AAST Grade 4 or 5 injuries. Only
four patients (3.2%) required nephrectomy and only
two (1.6%) required immediate surgical intervention.
Childrenʼs National Medical Center concluded that
initial non-surgical management of high-grade renal
trauma is recommended for hemodynamically stable
children. The AAST renal injury grading definitions are
given in Table One. In a 12-year retrospective series
from Baltimore of 79 patients ages 2-14 with renal
injury, 25% were Grade 4 or 5 injuries. 5 Seven (8.8%)
required nephrectomy, all of whom had Grade 5
injuries. Children who undergo conservative
management of renal injuries appear to have good
renal function in short- and long-term follow- up. 6 In a
series of 16 patients (12 of whom had high-grade
injuries) who were followed for one year post-injury,
all of the children had normal BUN, creatinine, and
blood pressure.
Current recommendations from the American
Academy of Pediatrics regarding children with an
absence of a kidney and participation in contact
sports emphasizes the need for clinical judgment and
individual assessment of both the patient and the
contact sport in question. 7 Several studies have
highlighted that the risk of renal loss from contact
sports is rare. 1
6 | Approaches in Critical Care | June 2011