Pediatric renal trauma at a level 1 trauma center in a rural state: A 10-year institutional review and protocol implementation

IntroductionUnintentional injury is a leading cause of mortality and morbidity in children. There is no consensus on the ideal, discrete management of pediatric renal trauma (PRT). Therefore, management protocols tend to be institution-specific.ObjectiveThis study aimed to characterize PRT at a rural level-1 trauma center and subsequently develop a stan-dardized protocol.Study designA retrospective review of a prospectively main-tained database of PRT at a rural level 1 trauma center between 2009 and 2019 was conducted. In-juries were characterized regarding renal trauma grade, associated multi-organ involvement and the need for intervention. The benefit of patient trans-fer from regional hospitals and length and cost of stay were evaluated.ResultsOf 250 patients admitted with renal trauma diag-nosis 50 patients <18 years were analyzed. Of those, the majority (32/50, 64%) had low-grade (grade I-III) injuries. Conservative management was successful in all low-grade injuries. Of 18 high-grade PRT, 10 (55.6%) required intervention, one prior to transfer. Among patients with low-grade trauma, 23/32 (72%) were transferred from an outside facility. A total of 13 (26%) patients with isolated low-grade renal trauma were transferred from regional hospitals. All isolated, transferred low-grade renal trauma had diagnostic imaging before transfer and none required invasive intervention. Interventional man-agement of renal injury was associated with a longer median LOS [7 (IQR = 4-16.5) vs 4 (IQR = 2-6) days for conservative management, p = 0.019)] and an increased median total cost of $57,986 vs. $18,042 for conservative management (p = 0.002).DiscussionThe majority of PRT, particularly low-grade, can be managed conservatively. A significant proportion of children with low-grade trauma are unnecessarily transferred to higher level centers. Review of pedi-atric renal trauma at our institution over a decade has allowed us to develop an institutional protocol which we believe allows for safe and effective patient monitoring.ConclusionIsolated, low-grade PRT can be managed conserva-tively at regional hospitals without needing transfer to a level 1 trauma center. Children with high-grade injuries should be closely monitored and are more likely to need invasive intervention. Development of a PRT protocol will help to safely triage this popu-lation and identify those who may benefit from transfer to a tertiary care center.