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Can Children who walk into the ED with

Microscopic Haematuria following Blunt Flank Trauma

safely walk out?

Dr Cara Jennings LDN/030/044/C

This manuscript is my own work and there has been no plagiarism

Word Count 3292

Electronically Signed 26/6/15

CanChildrenwhowalkintotheEDwithBluntFlankTraumaandMicroscopicHaematuria

safelywalkout?DrCaraJenningsLDN/030/044/C

2

Case

A 12-year-old boy walked in to the Emergency Department (ED) having fallen

from his skateboard. His observations were normal but he had bruising over

his left flank. Physical examination was otherwise unremarkable and his

abdomen was soft and non-tender. He had 2+ microscopic haematuria and a

normal FAST scan. I was unsure what the likelihood was of this patient

having a significant renal injury and therefore whether he could be discharged

safely without further investigations.

Introduction

Children with blunt flank injury pose a diagnostic problem in the ED. They

present with a variety of mechanisms of injury; low impact such as sporting

injury through to high impact such as falls from over five metres or motor

vehicle collision (MVC) >40mph(1). The latter group of patients usually arrive

by ambulance and should activate the major trauma pathway. These children

may have multiple injuries and many have a CT abdomen performed. The

low impact trauma patients often walk into the department. It can be difficult

to identify which of those children have significant renal injury especially in

younger children who have limited language and cannot describe pain and

tenderness(2). It is well recognised children can have normal parameters

even when they have lost a significant amount of blood so being

‘haemodynamically stable’ maybe falsely reassuring(3). It would be helpful to

have a marker of renal injury that was non-invasive and did not require a large

dose of radiation. FAST is not sensitive enough to rule out significant injury in

children and does not help in identifying renal injury(4). Formal ultrasound is



3

helpful but not immediately available. A CT scan of abdomen is not

appropriate as a screening tool as the dose of radiation is unacceptably

high(5). Urinalysis is easily performed in all age groups and gives rapid

results but how can the results help us determine injury severity?

A ‘Best BETs’ in 2000 confirmed that haemodynamically stable adults with

blunt flank trauma and microscopic haematuria could be safely discharged

without imaging, with advice to return if they become unwell or develop

macroscopic haematuria(6).

Children are more susceptible to renal injury than adults due to the relative

increased kidney size and reduced peri-renal fat(7). The kidneys are mobile

within Gerota’s fascia and they can be lacerated against ribs or vertebra

during deceleration injuries. Injuries range from grade I contusion, which may

be managed conservatively, through to grade V pedicle injuries, which

requires surgical intervention to re-vascularise and preserve renal

parenchyma. Grade II-IV lacerations often heal with non-operative

management although grade III-IV may still be considered significant as they

require careful monitoring and follow up (figure 1)(7, 8).

This clinical topic review proposes to determine whether children that walk

into the ED with microscopic haematuria following blunt flank trauma can be

discharged safely without imaging or whether such practice risks missing

clinically significant renal injury.



4

Figure 1: American Association of Surgery In Trauma Organ Injury

Severity Score for the Kidney (9)

Literature Review

A literature search was performed on Medline (1946-present), EMBASE

(1980-present) and CINAHL (1961-present) using the terms “blunt flank

trauma”, “blunt abdominal trauma”, combined with “paediatric” or “children”

and “microscopic haematuria” (the thesaurus was used to increase sensitivity

of search). The full search history can be seen in appendix 2. A manual

search of all the references cited in the articles was carried out.

Figure 2: Literature Search Strategy

LiteratureSearch

Criteria‐see

appendix2

Medline=18

EMBASE=24

CINAHL=0

Duplicatesremoved

27articles

considered

Excluded:17articles

notrelevantto

searchquestion

Included:Four

articlesreferenced

in27articles

14articlesdiscussed

inreview



5

The authors of the 14 journal articles were contacted to enquire if they were

aware of any unpublished research. The Cochrane database and NICE were

checked for existing reviews and guidelines. No further sources were found.

Literature Appraisal

Hynick et al published a retrospective case series of 571 children under 16

admitted to two level 1 trauma centres with blunt abdominal trauma(5). The

author used a scoring system devised by Holmes(2, 10, 11) to identify

patients who were at high risk of abdominal injury with a view to deciding

which patients required CT imaging. This scoring system was originally

devised to identify which children with blunt torso trauma were also at risk of

blunt abdominal trauma (BAT). These children are fundamentally different

from the stable, walk-in patients that this review proposes to address. The

scoring system comprises; presence of femoral fracture, raised AST/ALT, low

age adjusted BP on presentation, abdominal tenderness, microscopic

haematuria and low haematocrit. The author reported that patients with

haematuria were 2.8 [Odds Ratio (CI 1.8-4.3)] times more likely to have intra-

abdominal injury than those with no haematuria. Hynick did not differentiate

between macroscopic and microscopic haematuria. From this multi-variant

analysis it is difficult to pick out raw data i.e. many patients with microscopic

haematuria had a significant intra-abdominal injury. Hynick concluded that it

would be important to include haematuria if devising a decision-making

scoring system in paediatric BAT.



6

In 2002, Holmes et al conducted a prospective case series of 1095 children

under 16 presenting to an urban level one-trauma centre with blunt trauma (all

systems)(2). The authors reported clinical, laboratory and urine dipstick

findings as well as the presence of abdominal injury as found on CT/US/DPL

/laparotomy/post-mortem. Microscopic haematuria was defined as >5rbc/hpf

(see table 1) and gross haematuria as blood visible to naked eye. The

sensitivity of microscopic haematuria for detecting intra-abdominal injury was

50% [95% CI 40-60] with a specificity of 89% [95% CI 87-91], positive

predictive value 32%[95% CI 25-40] negative predictive value 94%[95% CI

93-96]. These were patients who met the trauma activation criteria for a

significant mechanism of injury and are not the walk-in patients with blunt

abdominal or flank trauma alone. There is no breakdown of the grade of

injury. This is important as other authors have discounted grade I injuries as

clinically insignificant. 431 (39%) of patients had no imaging and were simply

observed, 102 were admitted to hospital for serial examination and

haematocrit measurements, 329 were sent home from ED. Telephone follow

up was obtained in 89% of these patients and all were asymptomatic. Holmes

concludes that haematuria >5rbc/hpf is an important predictor of intra-

abdominal injury in children with blunt trauma.

Table 1: Correlation of results on urine dipstick to microscopy(13) Degree of Haematuria Red Blood Cells/High Powered Field

Occasional/ Trace <8

1+ 9-20

2+ 21-50

3+ 51-100

4+ >100



7

Nguyen et al carried out a retrospective case series on 46 paediatric blunt

trauma cases with objective evidence of renal injury on CT or laparotomy(7).

Grade I renal injuries were categorised as minor and grade II-V as major.

Two patients with >6<50 rbc/hpf were identified as having grade II/III renal

injury and six patients with >50rbc/hpf were identified as having grade II-V

injuries, one of whom required a nephrectomy. As all patients in this study

had a CT (or laparotomy) there is a selection bias, Nguyen set out to identify

which patients require CT but by only reviewing those that had CT performed

he misses the group of patients with low impact injuries that may be spared

radiographic imaging. Nguyen concludes that the decision to perform imaging

should be based on clinical findings and mechanism of injury rather than

urinalysis.

Morey et al carried out a retrospective case series on 180 blunt injured

children(12). 147 had microscopic haematuria; 70 of these were not imaged

and developed no further symptoms, the remaining 77 underwent intravenous

pyelography (IVP) or CT scanning. Only one patient was found to have a

significant (grade V) injury and had >50rbc/hpf, this patient unfortunately died

from multisystem trauma. The rest had either no injury or grade I injury

identified. Morey suggests a higher degree of suspicion in patients with >50

rbc/hpf. The population in Morey is relevant to this review, as they were all

patients presenting to ED with suspected renal trauma. There was a potential

for attrition bias as only 75 of 146 patients were followed up, these patients

recovered uneventfully. Morey concludes that patients with microscopic

haematuria alone should have no imaging initially, then weekly urinalysis with



8

renal ultrasound reserved for those patients with persistent microscopic

haematuria.

Brown et al carried out a retrospective case series of 1200 children presenting

to a level one trauma centre with blunt abdominal trauma(13). 65 were found

to have microscopic haematuria, 35 of whom underwent a CT scan of the

abdomen. Of those imaged, three were found to have significant renal injury

(grade IV-V) but in all cases the clinical presentation was suggestive of

multiple intra-abdominal injuries (unlike the target population of this review).

Two were found to have liver lacerations and the other, a splenic laceration.

20 out of 62 patients diagnosed clinically or radiologically with renal

contusions were followed up in outpatients and had an ‘uneventful

convalescence’. The authors suggest that children with blunt abdominal

trauma (BAT), microscopic haematuria and no associated injuries should not

undergo radiological investigation, as significant renal injury is unlikely.

However, children with associated injuries should undergo CT evaluation

regardless of the degree of haematuria. The authors also suggest that

children with persistent haematuria at 30 days should have imaging.

Bass et al carried out a retrospective case review in 1991 in children under 13

with BAT(14). He found that of 155 children with <3+ haematuria one had a

grade II injury on IVP and the rest had grade I injury or normal IVP. Of 72

children with 4+ microscopic haematuria nine had grade II-V renal injury, one

of which required surgical intervention. The authors suggested that contrast



9

studies be reserved for patients with gross haematuria or >4+ microscopic

haematuria and those with loin tenderness or mass.

Abou-Jaoude et al found, in a retrospective case series of children with blunt

trauma and haematuria, that of 19 patients with haematuria <20 rbc/hpf three

had minor injuries and two had major injuries as identified on IVU or CT(15).

The criteria for performing these investigations was haematuria >10rbc/hpf or

high clinical suspicion. Abou-Jaoude found that 89% of those with a renal

injury had positive physical findings such as tenderness or pelvic instability.

50% of the patients with major injuries had associated injuries, nine had a

pelvic fracture, these patients obviously couldn’t ‘walk-in’. The authors noted

that one patient with asymptomatic haematuria (i.e. no shock or other injury)

had an injury and that was a renal contusion. The authors conclude that the

decision to image patients for renal injury should be based on clinical

judgment rather than the presence of haematuria. He also states that the

approach in adults of limiting investigations to patients with macroscopic

haematuria or microscopic haematuria and shock identifies the vast majority

of significant injuries in children.

Taylor et al performed a retrospective case series on 378 children who had

CT for BAT and found 220 patients with microscopic haematuria; 57 of which

had an abnormal CT, 21 were thought to have clinically significant injuries

(renal, spleen, liver)(16). Twelve were found to have renal injury although the

grade is not specified. The patients in his study that were found to have a

significant injury with microscopic haematuria had an average injury severity



10

score of 25 and were stable after initial resuscitation suggesting some

presented in shock, once again these patients are not the walk-in patients of

interest. It was concluded that patients with asymptomatic haematuria of any

degree can be managed conservatively but those with tenderness, swelling or

contusions should undergo imaging.

Pietrera et al in their prospective case series of children with blunt trauma and

renal lesions showed that of eight patients with microscopic haematuria five

had either a fracture of the kidney or a pedicle injury(17). The mechanism

varied from MVC to falls from height, it was unclear if they presented in shock

or had concomitant injuries and therefore these patients are different from our

walk-in group. The author claimed there is no correlation between degree of

haematuria and severity of injury.

Levy et al performed a small retrospective case series on children with

BAT(8). Levy found that out of 48 patients with microscopic haematuria only

three had a significant renal injury. All three patients had ‘associated

multisystem trauma’; closed head injury, long-bone fractures, other intra-

abdominal injury. Levy concludes associated multisystem trauma is predictive

of a major renal injury in the setting of microscopic haematuria (p<0.01).

He et al performed a small retrospective case series of 84 children with blunt

renal trauma and found that of 84 patients with microscopic haematuria 22

had grade I-III injuries which He regarded as insignificant, none were found to

have grade IV to V injuries(18).



11

Moller et al carried out a retrospective case series of 114 patients with blunt

renal trauma, including 20 children, the major trauma patients were

excluded(19). None of the children with microscopic haematuria had a major

injury. Moller describes a 13-year-old with blunt flank injury and severe pain

who went onto have an ultrasound and IVP showing a large renal laceration,

she did not have her urine examined so it is impossible to know what degree

of haematuria she had. Despite this, Moller concludes that children under 15

should have imaging independent of the degree of haematuria. Moller’s own

work doesn’t support this conclusion but he cites a previous study Stalker et

al(20) in making the conclusion. Stalker carried out a retrospective case

series on 256 children with BAT who had a CT abdomen. Three patients had

>grade III injuries with >100rbc/hpf. One patient had a renal pedicle injury

and no haematuria: however that child presented in shock. Stalker concludes

that significant renal injury would not have been missed if CT were omitted in

those whose only abnormality is a small amount of microscopic haematuria

(<50rbc/hpf). It is not clear why Moller drew a different conclusion from

Stalker.

Stein et al reviewed the cases of 412 children presenting to the ED following

major trauma(3). He found that 17/25 (68%) of patients with significant renal

injury had microscopic haematuria, of whom seven had no shock or other

abdominal injuries. 15/25 had other non-abdominal injuries but it is not clear if

the seven without shock were amongst these. The author defines significant

injury as any renal laceration or pedicle injury. There is a significant selection



12

bias in that the children were all ‘major trauma’ patients who had required CT

abdomen. Stein claims he found no correlation between degree of

haematuria and degree of renal injury. Stein’s proposal is that all children

with blunt abdominal trauma and haematuria should undergo abdominal and

pelvic computed tomography.

Discussion

All of the 14 papers included in this review were case series, published

between 1988 and 2014. These would be classified as Level Four evidence

according to the Oxford Centre for Evidence Based Medicine (19). There was

no single paper that exactly addressed my search question but within the

papers were relevant results.

Some papers discussed flank trauma, some renal trauma and some blunt

abdominal trauma. All were included as the flank is ill defined and the

younger the child the greater the difficulty in determining the exact point of

impact.

There is variety in how a significant renal injury is defined, some authors

suggest grade I-III are clinically insignificant and others suggest anything

greater than grade I is significant. This makes it difficult to compare studies.

None of the articles grouped children into smaller age categories. It is difficult

to assess children under five years old due to their limited communication.



13

Only two of the 14 studies were prospective and this is likely to have created

a significant limitation as patients who walked into the ED with BAT and

microscopic haematuria may not have been included in the retrospective case

series due to inaccuracies in coding as I found in my personal work.

Four of the 14 studies only considered patients who had undergone CT

scanning. This creates a selection bias as those who were thought to require

CT are likely to be the high impact, multiply injured patients who have a higher

pre-test probability of significant renal or other abdominal injury.

Many papers used IVP to grade injuries. This imaging modality is now

obsolete having been replaced with CT. Despite this the results are still

pertinent as the correlation between severity of injury and degree of

haematuria can be ascertained.

Most studies used patients with multiple injuries, ‘major trauma’ patients. It is

well recognised that renal pedicle injuries can present without haematuria(7):

however this is a high-energy injury and therefore these patients are probably

major trauma patients. Major trauma patients are likely to have a higher

grade of injury and other intra-abdominal and extra-abdominal injuries. Whilst

I have extrapolated the findings from the multiply injured patients to the walk-

in patients, it must be clear that there should be a higher degree of suspicion

in major trauma patients and the degree of haematuria should not decide

whether they require imaging.



14

Many of the studies contained small numbers of patients. Some such as

Stein and Pietrera claimed there was no correlation between degree of

haematuria and grade of injury; this could be a type 2 statistical error due to

the sample size.

The challenges of research in paediatric trauma are evident when considering

these articles. A prospective multi-centre study examining the role of

urinalysis in blunt flank trauma would be pertinent. This would help guide the

clinician’s decision making in the low-impact trauma patient who walks into

the department. In the context of ‘major trauma’ a well-conducted study may

reduce the reliance on CT scanning in stable patients. Ideally urine samples

would be tested and the lead clinician would be blinded as to the result. He/

she would make treatment decisions based on mechanism and examination

findings. The patient outcome could then be compared to urinalysis findings.

Large numbers of patients would be required to be statistically significant.

Personal Work

I performed a retrospective review of the clinical notes of all children

presenting with blunt trauma to the ED at King’s College Hospital London, a

level one-trauma centre, from August 2013 to August 2014. Over 300

patients were found following a search for children under 16 years with blunt

trauma/injury. It was not possible to search for flank injury or blunt abdominal

trauma. Many patients were excluded as isolated head injury, burns, limb

injury etc. I read the medical records of all the remaining patients to find



15

those with blunt flank trauma/ BAT. I did not exclude ‘major trauma’ patients

as many of those coded as ‘major trauma’ in fact had low impact injuries.

I found 54 patients who presented with blunt abdominal trauma or a fall onto

the back. Many of these did not have documented urinalysis. This could be

because it is not being performed, but also the results are printed on a small

piece of paper, which may be misplaced.

There were 13 patients with blunt abdominal trauma and microscopic

haematuria, age range 4-14 years old. Mechanisms varied from fall down

four stairs to being hit by a car, these were not all walk-in patients (see

appendix 4). Three had a negative FAST scan, there were no positive FAST

scans; one had a contrast ultrasound, which was negative. Three had CT

abdomen/pelvis; two had splenic lacerations but no renal injury. These

patients had 2+ and 3+ haematuria and were ‘major trauma’ patients

(pedestrian hit by car at 30mph and jumped from 2nd floor window

respectively). The third patient who underwent CT had pelvic fractures, 3+

haematuria on urinalysis but no renal injury. None of the patients presented

in shock and none required surgical intervention.

I believe, from my experience in neighbouring district general hospitals and

anecdotally, that blunt flank trauma in the paediatric population is more

common than these findings suggest. I suspect they are being coded as

abdominal pain or back pain and therefore didn’t appear in my search. Many

of the patients in my series didn’t have urinalysis recorded and had a CT



16

abdomen. In my experience of DGHs, performing a CT scan on a child is rare

and there is more reliance on basic investigations such as urinalysis coupled

with close monitoring.

With the conclusions from my literature review and the findings in my

department I designed a guideline to be used in these patients. This guideline

was discussed with the local paediatric surgeons, paediatric urologists, short

stay unit paediatricians, paediatric radiologists and paediatric emergency

medicine consultants. The paediatric radiologists were helpful in their

suggestions regarding imaging modality and they were keen to adopt a

conservative approach imaging all children with >50rbc/hpf ideally before

discharge. The guideline was then presented at the paediatric governance

meeting and the ED core group meeting. This has now been accepted as a

Standard Operating Procedure and is being uploaded onto Kwiki, the trust

intranet collection of guidelines and SOPs. An advice sheet for parents was

also developed. See appendices 5 and 6.

Conclusion

The presence of microscopic haematuria alone is not a sensitive marker for

renal injury and should be interpreted as part of the wider clinical picture.

However, haemodynamically stable patients who walk into the department

with blunt flank trauma and microscopic haematuria < 50rbc/hpf are highly

unlikely to have a clinically significant renal injury and can be safely

discharged. Patients with >50rbc/hpf have a very small risk of clinically



17

significant injury, a conservative approach would be to perform renal

ultrasound on them within a 24 hours of presentation.

References

1. Jordan R, Westacott D, Patel H, Pattison G. The effect of regional trauma networks on paediatric trauma care in an integrated adult service. Eur J Emerg Med. 2014 Jun 18. 2. Holmes JF, Sokolove PE, Brant WE, Palchak MJ, Vance CW, Owings JT, et al. Identification of children with intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2002 May;39(5):500-9. 3. Stein JP, Kaji DM, Eastham J, Freeman JA, Esrig D, Hardy BE. Blunt renal trauma in the pediatric population: indications for radiographic evaluation. Urology. 1994 Sep;44(3):406-10. 4. Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, et al. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. J Trauma. 2000 May;48(5):902-6. 5. Hynick NH, Brennan M, Schmit P, Noseworthy S, Yanchar NL. Identification of blunt abdominal injuries in children. J Trauma Acute Care Surg. 2014 Jan;76(1):95-100. 6. Saunders F, Argall J. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Investigating microscopic haematuria in blunt abdominal trauma. Emerg Med J. 2002 Jul;19(4):322-3. 7. Nguyen MM, Das S. Pediatric renal trauma. Urology. 2002 May;59(5):762-6; discussion 6-7. 8. Levy JB, Baskin LS, Ewalt DH, Zderic SA, Bellah R, Snyder HM, 3rd, et al. Nonoperative management of blunt pediatric major renal trauma. Urology. 1993 Oct;42(4):418-24. 9. Miller KS, McAninch JW. Radiographic assessment of renal trauma: our 15-year experience. J Urol. 1995 Aug;154(2 Pt 1):352-5. 10. Holmes JF, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009 Oct;54(4):528-33. 11. Holmes JF, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, et al. Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-16 e2.



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12. Morey AF, Bruce JE, McAninch JW. Efficacy of radiographic imaging in pediatric blunt renal trauma. J Urol. 1996 Dec;156(6):2014-8. 13. Brown SL, Haas C, Dinchman KH, Elder JS, Spirnak JP. Radiologic evaluation of pediatric blunt renal trauma in patients with microscopic hematuria. World J Surg. 2001 Dec;25(12):1557-60. 14. Bass DH, Semple PL, Cywes S. Investigation and management of blunt renal injuries in children: a review of 11 years' experience. J Pediatr Surg. 1991 Feb;26(2):196-200. 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 Jan;31(1):86-9; discussion 90. 16. Taylor GA, Eichelberger MR, Potter BM. Hematuria. A marker of abdominal injury in children after blunt trauma. Ann Surg. 1988 Dec;208(6):688-93. 17. Pietrera P, Badachi Y, Liard A, Dacher JN. [Ultrasound for initial evaluation of post-traumatic renal lesions in children]. J Radiol. 2001 Jul;82(7):833-8. 18. He B, Lin T, Wei G, He D, Li X. Management of blunt renal trauma: an experience in 84 children. Int Urol Nephrol. 2011 Dec;43(4):937-42. 19. Moller CM, Mommsen S, Dyreborg U. The role of haematuria in the diagnosis of blunt renal trauma. Scand J Urol Nephrol Suppl. 1995;172:99-101. 20. Stalker HP, Kaufman RA, Stedje K. The significance of hematuria in children after blunt abdominal trauma. AJR Am J Roentgenol. 1990 Mar;154(3):569-71. Appendices Appendix 1: Abbreviations Used AKI – Acute kidney injury ALT - Alanine aminotransferase AST – Aspartate aminotransferase BAT – Blunt Abdominal Trauma CI – Confidence Interval CT – Computed Tomography DGH – District General Hospital DPL – Diagnostic Peritoneal Lavage ED - Emergency Department



19

FAST – Focussed Assessment Sonography in Trauma GCS – Glasgow Coma Score IAI – Intra-abdominal injury IVP – Intravenous Pyelogram MVC – Motor vehicle collision OR – Odds Ratio Rbc/hpf – Red blood cells/ high powered field SOP – Standard operating procedure US – Ultrasound Appendix 2: Search Strategy The following search was performed on Medline, Embase and CINAHL:

1. (“blunt abdominal trauma” OR “renal inju*” OR “renal trauma” OR “flank injur*” OR “flank trauma” OR “blunt abdominal injur*”) - title or abstract

2. ABDOMINAL INJURIES/ 3. WOUNDS, NONPENETRATING/ 4. 2 OR 3 5. 1 OR 4 6. (haematuria OR hematuria) - title or abstract 7. HEMATURIA/ 8. microscopic - any field 9. 6 OR 7 10. 8 AND 9 11. (child OR children OR pediatric OR paediatric) – title or abstract 12. 5 AND 10 AND 11

Appendix 3: Evidence Table

Author,

date

Patient

Group

StudyDesign Outcomes KeyResults StudyWeaknesses

Hynick

NHetal,

2014

571patients

under16

yearswith

BAT

Retrospective

caseseries

Significant

intra‐

abdominal

injury

Haematuriahas2.8

oddsratio(1.8‐4.3)

forsignificantIAI

Multi‐variantanalysis–

can’tpickoutrawdata.

WideCIonOR.

Holmes

JFetal,

2002,

1095children

<16years

withblunt

trauma

Prospective

caseseries

Significant

intra‐

abdominal

injury

Urinalysis>5

RBCs/hpf50%

sensitive,89%

specific,PPV32%

andNPV94%for

intra‐abdominal

injury

Majortraumapatients.

Rawdata;i.e.no.patients

withmicroscopic

haematuriaand

significantIAInotshown

Nguyen,

MMetal,

2001,

61patients<

18ywithCT

evidence

renalinjury

Retrospective

caseseries

Significant

renal

injury

(grade

8/15patientswith

microscopic

haematuria

Allpatientsincludedhad

CT.Selectionbiashigher‐

gradeinjury.



20

posttrauma II=V)

BrownSL

etal,

2001

299children

<18years

withBAT

Retrospective

caseseries

Significant

renal

injury

3/65patientswith

microscopic

haematuria

3/65patientshad

multipleabdominal

injuries

HeBet

al,2001

84children

withblunt

renaltrauma

inurinary

surgery

centre

Retrospective

caseseries

Significant

renal

injury

0/84patientswith

microscopic

haematuria

Pietrera

etal,

2001

17children

withpost

traumatic

renallesions

identifiedon

colour

DopplerUS

andCT/IVP

Prospective

caseseries

Significant

renal

injury–

‘fracture’

orpedicle

lesion

5/8withmicroscopic

haematuria

Non‐Englishlanguage

paper.

Abou‐

Jaoudeet

al,1996,

100children

withBAT

Retrospective

caseseries

Renal

injuryor

congenital

abnormalit

y

3/100patientswith

microscopic

haematuriahad

significantinjury

Nopatientshad

significantinjuryand

‘asymptomatic’

haematuria

MoreyAF

etal,

1996,

180children

inEDwith

suspected

renalinjury

Caseseries Significant

renal

injury

1/147patientswith

microscopic

haematuria

70/147patientswith

microscopichaematuria

hadnoimaging

Molleret

al,1995,

20children

withblunt

renaltrauma

Retrospective

caseseries

Severe

renal

injury

0/20hadmajor

injury

UseofIVPtogradeinjury

–obsolete.

Levyet

al,1993

58children

enteredinto

trauma

registrywith

BAT

Retrospective

caseseries

Significant

renal

injury

3/48patientswith

microscopic

haematuria

All3patientshad

multisystemtrauma.

BassDH

etal,

1991

587children

<13years

withBAT

Retrospective

caseseries

Significant

renal

injury

2/155patientswith

<3+microscopic

haematuria

17/72patientswith

4+microscopic

haematuria

>20yearsold–IVP

obsoleteinvestigation

Stalkeret

al,1990

256patients

whohadCT

abdo

followingBAT

Retrospective

caseseries

Significant

renal

injury

Nonormotensive

childwith

<50rbc/hpf

Doesn’tgivenumberof

patientswith

microhaematuriaand

injuryofanyseverity

Tayloret

al,1988

378children

whohadCT

followingBAT

Retrospective

caseseries

Significant

intra‐

abdominal

injury

21/220patientswith

microscopic

haematuria

12/220hadrenalinjury–

grade/severity

unspecified

Appendix 4:



21

Children with BAT and microscopic haematuria from August 2013 to 2014 at King’s College Hospital, London

Age Mechanism Urinalysis Imaging Outcome Return Discharge

Advice

6 60mph MVC Trace FAST –ve 6 hours

observation – home

No Verbal

13 Fall from horse 1+ Nil 6 hours

observation-

home

No Verbal

13 Fall from horse Trace Contrast US

– no injury

48 hours – MRI

neck

No Verbal

10 Fall on

trampoline

Trace Trauma

series X-ray

Observed 2 hours

- home

No Verbal

14 Fall down 4

stairs

Trace FAST –ve Observed 2 hours

– home

No Verbal

13 Fell from

garage roof

1+ FAST –ve Observed 48

hours- extradural haematoma

No Verbal

5 Jumped from

1st floor window

Trace Nil Observed four

hours

No Verbal

6 Fell down 6

stairs

3+ Nil Observed

overnight

No Verbal

15 Jumped from 2nd floor

window

3+ CT abdo/ pelvis – no

renal injury

grade 2

splenic laceration

Observed four days

No Verbal

9 Cyclist hit by

car

Trace Facial X-ray Observed 48

hours

No Verbal

4 Pedestrian vs. car 30mph

1+ Nil Discharged 4 hours

No Verbal

14 MVC 2+ CT

abdo/pelvis – splenic

laceration

grade2/3

Discharged 3

days

No Verbal

5 Pedestrian vs. car 30mph

3+ CT chest/abdo/

pelvis –

pelvic fracture,

pulmonary

contusion

Discharged 4 days

No Verbal

Appendix 5:



22

SOP for Children with Microscopic Haematuria following Blunt Flank Trauma in ED

Appendix 6: Patient advice leaflet to be given to parents/ carers of all children with microscopic or no haematuria

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