Pediatric Trauma (Campbell Review 12th Ed Chapter Review)

Question 1

Which pediatric renal trauma grades can be managed non operatively?

Answer 1

The majority of renal trauma can be managed nonoperatively. Grade
4–5 injuries can be managed nonoperatively but have higher risk of
undergoing intervention.

Question 2

How do you manage persistent or delayed bleeding in grade 3-5 pediatric renal injuries managed non operatively?

Answer 2

Around 25% of patients with grade 3–5 injuries being managed
nonoperatively will have persistent or delayed bleeding.
Superselective angioembolization of bleeding vessels is very
successful and is the preferred method for management. Repeat
angioembolization can also be successful if initial attempt fails.

Question 3

What percentage of patients with urine leak managed non operatively will have an indication for intervention in pediatric renal trauma? What are the options?

Answer 3

Around 15% of patients with a urine leak being managed
nonoperatively will have indication for intervention such as ureteral
stent placement and/or percutaneous drain placement.

Question 4

In pediatric grade 1-3 renal injuries managed non operatively, is there a need to do routine repeat imaging?

Answer 4

Repeat CT imaging 48–72 h after injury is not needed for patients
with grade 1–3 injuries who are recovering without complication.
Repeat CT imaging in 48–72 h may be obtained in patients with
grade 4–5 injuries but is of unclear utility if the patient is stable and
recovering without apparent complication.

Question 5

What are the indications for operative intervention in pediatric renal trauma?

Answer 5

Indications for operative intervention include hemodynamic
instability due to renal bleeding, pulsatile or expanding
retroperitoneal hematoma at time of laparotomy without prior renal
imaging, and failure of angioembolization to control renal bleeding.

Question 6

When should renal vascular control be done in pediatric renal trauma?

Answer 6

Control of renal vascular should be performed immediately after
opening Gerota fascia or prior to opening Gerota fascia.

Question 7

What is the dictum in operative intervention regarding nephrectomy in pediatric injuries?

Answer 7

Operative intervention should include attempts to salvage kidney if
possible.

Question 8

When should you repair pediatric UPJ disruptions?

Answer 8

UPJ disruptions should be repaired in acute phase if patient is stable;
otherwise drainage with nephrostomy tube and possible
percutaneous perirenal drain with delayed repair should be
performed.

Question 9

How are pediatric renal pelvis ruptures managed?

Answer 9

Renal pelvis ruptures may require operative intervention but have
been managed successfully with endoscopic and percutaneous
urinary drainage.

Question 10

How high is the risk of renal scarring in high grade renal injuries (grade 4-5)?

Answer 10

The risk of renal scarring is negligible in grade 1–2 injuries, approximately 50% in grade 3 injuries, and 100% in grade 4–5 injuries.

Question 11

What are the options for follow-up imaging in pediatric grade 3-5 renal injuries?

Answer 11

Follow-up imaging for grade 3–5 injuries should be considered.
Starting with a renal ultrasound and obtaining CT, MRI, or DMSA
scan if necessary is a common approach.

Question 12

In what grade of injuries can hypertension be seen after pediatric renal trauma?

Answer 12

Hypertension is a rare occurrence after renal trauma in children and
typically is only seen after grade 3–5 injuries.

Question 13

Is CKD or ESRD common after nephrectomy in pediatric renal trauma?

Answer 13

The development of chronic kidney disease or end-stage renal
disease is very rare after renal trauma even when nephrectomy is
performed.

Question 14

How do you advise patients with solitary kidneys regarding their participation in contact sports?

Answer 14

Patients with a normal solitary kidney can participate in sports, but
protective equipment is recommended for contact sports. High-risk
activities include dirt bike riding, cycling, and all-terrain vehicle
riding.

Question 15

Where are ureteral injuries more common? blunt or penetrating trauma?

Answer 15

Ureteral injuries are rare with any type of trauma but are most
commonly seen with penetrating trauma.

Question 16

What is the preferred imaging to diagnose ureteral inury?

Answer 16

A contrast-enhanced CT scan with delayed phase or a retrograde
pyelogram is the preferred methods to diagnose a ureteral injury.

Question 17

How do you manage ureteral injuries in the <1 week vs >1 week from injury?

Answer 17

Ureteral injuries are often associated with other organ injuries in
trauma cases and can be missed at initial laparotomy for trauma.
If a ureteral injury is diagnosed <1 week from injury, immediate
repair can be performed and may be preferable if patient is stable.
If a ureteral injury is diagnosed >1 week from injury, an attempt at
ureteral stent placement can be made, but often a nephrostomy tube
with delayed open repair is needed.

Question 18

How do you evaluate pediatric gross hematuria with a history of pelvic trauma?

Answer 18

A history of pelvic trauma with gross hematuria or inability to void,
and pelvic fracture necessitate urologic evaluation with retrograde
urethrogram and/or cystogram.

Question 19

What are the indications to repair an extraperitoneal bladder rupture?

Answer 19

Indications to repair an extraperitoneal bladder rupture include need
for placement of orthopedic hardware in the field, bony pelvis
fragments protruding into the bladder, involvement of the bladder
neck in the injury, and concurrent abdominal surgery.

Question 20

How do you manage intraperitoneal bladder ruptures? How about bladder neck injuries?

Answer 20

Intraperitoneal bladder ruptures are managed with surgical repair.

Bladder neck injuries are more common in children and best served
with early repair.

Question 21

What other organs do you need to check for injuries if there is genital injury?

Answer 21

Genital injury in children should raise suspicion for abuse, and if
abuse is suspected, concomitant injury to the rectum and anus should
be ruled out.

Question 22

How do you avoid circumcision injuries?

Answer 22

Most circumcision injuries can probably be avoided by ensuring that
adhesions are properly reduced at the beginning of the procedure.

Question 23

If there is suspicion for testicular rupture in ultrasound, what is the best management?

Answer 23

Findings on ultrasound consistent with testicular rupture should
prompt surgical exploration.

Question 24

In pediatric vaginal injuries, what are the signs of penetrative injury that prompts evaluation for abuse?

Answer 24

Straddle injuries make up the majority of vaginal injuries. Injuries to
bladder, urethra, anus, rectum, hymen, and internal vaginal structures
are suggestive of penetrative injury and should prompt evaluation for
abuse.