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A 10-year-old girl with history of trauma, abdominal pain, and hematuria
A
10-year-old girl c a m e to t h e e m e r g e n c y d e p a r t m e n t a p p r o x i m a t e l y 90 m i n u t e s after colliding w i t h her b r o t h e r w h i l e r i d i n g h e r bicycle. She h a d b e e n t h r o w n over t h e h a n d l e b a r s a n d h a d s t r u c k t h e r i g h t s i d e of her a b d o m e n a n d right lower a s p e c t of her c h e s t on t h e h a n d l e b a r s . She h a d n o t b e e n w e a r i n g a h e l m e t . T h e child w a s a m b u l a t o r y a n d r e p o r t e d a b d o m i n a l pain, n a u s e a , a n d vomiting. Her m o t h e r h a d b e c o m e c o n c e r n e d a n d b r o u g h t h e r to t h e e m e r g e n c y d e p a r t m e n t w h e n t h e child v o i d e d b r i g h t r e d blood. P h y s i c a l e x a m i n a t i o n r e v e a l e d a child w h o w a s alert a n d oriented. Her skin w a s w a r m a n d dry. Her a b d o m e n w a s soft a n d fiat b u t s i g n i f i c a n t l y t e n d e r on p a l p a t i o n of t h e r i g h t side. A c o n t u s i o n w a s n o t e d on t h e r i g h t p o s t e r i o r axillary line. T h e r e w a s also marked right costovertebral angle tenderness. The l u n g s w e r e clear on a u s c u l t a t i o n . T h e r e w e r e no other a p p a r e n t injuries. Vital s i g n s w e r e a s follows: t e m p e r a t u r e , 36.6 ~ C orally; p u l s e , 92 b e a t s / m i n ; r e s p i r a t i o n s , 20 p e r m i n u t e ; b l o o d p r e s s u r e , 101/63 m m Hg.
d y n a m i c s t a t u s r e m a i n e d s t a b l e , b u t s h e w a s still u n a b l e to void. A c h e s t r a d i o g r a p h s h o w e d a fract u r e d t e n t h r i g h t rib w i t h o u t e v i d e n c e of p n e u mothorax. In t h e r a d i o l o g y d e p a r t m e n t , t h e p a t i e n t w a s u n a b l e to lie fiat on t h e t a b l e for t h e CT s t u d y b e c a u s e of a d r a m a t i c i n c r e a s e in a b d o m i n a l p a i n . T h e CT s c a n w a s c o m p l e t e d a f t e r t h e p a t i e n t received meperidine. The scan showed a severe r i g h t r e n a l i n j u r y w i t h e x t e n s i v e e x t r a v a s a t i o n of contrast material into the renal parenchyma and extravasating outside the kidney. Bleeding was also n o t e d in t h e r e n a l c o n a l f a s c i a on t h e r i g h t
A c o n t u s i o n w a s n o t e d on t h e right p o s t e r i o r axillary line. T h e r e w a s a l s o m a r k e d right c o s t o v e r t e b r a l a n g l e tenderness.
What do you suspect? Discussion T h e p a t i e n t w a s t a k e n i m m e d i a t e l y to a n e x a m i n a tion r o o m a n d c a r d i a c m o n i t o r i n g d e m o n s t r a t e d normal s i n u s r h y t h m . A n i n t r a v e n o u s c a t h e t e r w a s i n s e r t e d a n d a n infusion w a s started. L a b o r a t o r y specimens were obtained, including a complete blood cell c o u n t a n d d e t e r m i n a t i o n of s e r u m a m y l a s e c o n c e n t r a t i o n s a n d electrolyte levels. The patient vomited twice and reported worseni n g of a b d o m i n a l p a i n while w a i t i n g for a c o m p u t e d t o m o g r a p h i c (CT) s c a n to b e a r r a n g e d . H e r h e m o Jacqueline Mador is a staff nurse, Emergency Department, Southern Maine Medical Center, Biddeford, Maine. Reprints not available from author. J Emerg Nurs 1996;22:358-9. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/1/73647
358
Volume 22, Number 4
s i d e . T h e r e w a s n o e v i d e n c e of u r e t e r a l a v u l s i o n , or i n t r a p e r i t o n e a l or r e t r o p e r i t o n e a ] h e m o r r h a g e . I n j u r y to t h e k i d n e y , e s p e c i a l l y in c h i l d r e n , is a c o m m o n result of b l u n t t r a u m a . A l m o s t 80% of all r e n a l injuries in c h i l d r e n are r e l a t e d to b l u n t trauma. Children's proportionally larger kidneys, weaker a b d o m i n a l m u s c l e s , m o r e flexible rib c a g e s , a n d less p e r i r e n a l fat all c o n t r i b u t e to r e n d e r t h e m m o r e s u s c e p t i b l e to renal injury. A child w i t h a renal injury m a y h a v e no s y m p t o m s or m a y report a b d o m i n a l pain. A l t h o u g h h e m a t u r i a is a c o m m o n finding a n d occurs in u p to 96% of all c a s e s of renal trauma, t h e r e is no correlation b e t w e e n t h e a m o u n t of h e m a t u r i a a n d t h e s e v e r i t y of the injury There m a y also b e a s s o c i a t e d flank pain, contusions, flank e c c h y m o s i s (known as Grey Turner's sign), periumbilical e c c h y m o s i s (known a s Cullen's sign), n a u sea, v o m i t i n g , a n d h e m o d y n a m i c instability.
Mador/JOURNAL OF EMERGENCYNURSING
T h e girl's h e m o d y n a m i c s t a t u s r e m a i n e d stable, as did h er h e m o g l o b i n a n d h e m a t o c r i t levels. Her c o n d i t i o n w a s m a n a g e d c o n s e r v a t i v e l y in t h e intens i v e c a r e u n i t w i t h i n t r a v e n o u s fluids a n d serial CT
The child's presentation warranted immediate evaluation, despite her normal signs and ambulatory status. In particular, the finding of pain w i t h history of bright red blood in the patient's urine s u g g e s t s significant injury. s c a n s . S h e w a s d i s c h a r g e d 9 d a y s later w i t h o u t significant complications.
T h e m e c h a n i s m of injury is clearly d e s c r i b e d in this case, b u t a c c i d e n t s i n v o l v i n g b i c y c l e s c a n easily result in straddle injuries, w h i c h m a y b e difficult to identify in a child. Straddle injuries c a n c a u s e large h e m a t o m a s a n d l a c e r a t i o n s of t h e p e r i n e u m . Girls m a y also e x p e r i e n c e v a g i n a l lacerations, p r o d u c i n g b r i g h t r ed blood at t h e p e r i n e u m w i t h an u n c l e a r source. I n t r a p e r i t o n e a l injury c a n also occur. T h e peri n e u m m u s t b e v i s u a l i z e d in a m o r e p r i v at e a r e a w h e n e v a l u a t i n g t h e relative a c u i t y of a straddle injury. Pelvic fractures m a y also p r o d u c e si g n s a n d s y m p t o m s similar to t h o s e d e s c r i b e d in this case. T h e possibility of pelvic fracture, w i t h c o n c o m i t a n t urethral damage, should be considered before catheterization attempts.
Suggested readings Allshouse M, Betts J. Genitourinary injury. In: Eichelberger M, editor. Pediatric trauma prevention, acute care, rehabilitation. St Louis: Mosby-Year Book, 1993:503-8. Gausche M. Genitourinary trauma. In: Barkin R, editor. Pediatric emergency medicine, concepts and clinical practice. St Louis: Mosby-Year Book, 1992:292-7.
Section editor's teaching points T h e child's p r e s e n t a t i o n w a r r a n t e d i m m e d i a t e evaluation, d e s p i t e her n o r m a l vital s i g n s a n d a m b u l a t o r y status. In particular, t h e f i n d i n g of p a i n w i t h history of b r i g h t red blood in t h e p a t i e n t ' s u r in e s u g g e s t s sign i f i c a n t injury.
Contributions f o r this column shouM be sent to Lisa Molitor, ARNP, MSN, CEN, CCRN, 8404 S.W. 28th Place, Gainesville, FL 32607. phone (904) 331-1781.
AVAILABILITY OF Journal BACK ISSUES As a service to our subscribers, copies of back issues of Journal of Emergency Nursing for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $9.00 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or mare. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, Me 63146-3318, or call (800) 453-4351 or (314) 4534351 for information on the availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106; (313) 761-4700.
August 1996 359
10-year-old girl c a m e to t h e e m e r g e n c y d e p a r t m e n t a p p r o x i m a t e l y 90 m i n u t e s after colliding w i t h her b r o t h e r w h i l e r i d i n g h e r bicycle. She h a d b e e n t h r o w n over t h e h a n d l e b a r s a n d h a d s t r u c k t h e r i g h t s i d e of her a b d o m e n a n d right lower a s p e c t of her c h e s t on t h e h a n d l e b a r s . She h a d n o t b e e n w e a r i n g a h e l m e t . T h e child w a s a m b u l a t o r y a n d r e p o r t e d a b d o m i n a l pain, n a u s e a , a n d vomiting. Her m o t h e r h a d b e c o m e c o n c e r n e d a n d b r o u g h t h e r to t h e e m e r g e n c y d e p a r t m e n t w h e n t h e child v o i d e d b r i g h t r e d blood. P h y s i c a l e x a m i n a t i o n r e v e a l e d a child w h o w a s alert a n d oriented. Her skin w a s w a r m a n d dry. Her a b d o m e n w a s soft a n d fiat b u t s i g n i f i c a n t l y t e n d e r on p a l p a t i o n of t h e r i g h t side. A c o n t u s i o n w a s n o t e d on t h e r i g h t p o s t e r i o r axillary line. T h e r e w a s also marked right costovertebral angle tenderness. The l u n g s w e r e clear on a u s c u l t a t i o n . T h e r e w e r e no other a p p a r e n t injuries. Vital s i g n s w e r e a s follows: t e m p e r a t u r e , 36.6 ~ C orally; p u l s e , 92 b e a t s / m i n ; r e s p i r a t i o n s , 20 p e r m i n u t e ; b l o o d p r e s s u r e , 101/63 m m Hg.
d y n a m i c s t a t u s r e m a i n e d s t a b l e , b u t s h e w a s still u n a b l e to void. A c h e s t r a d i o g r a p h s h o w e d a fract u r e d t e n t h r i g h t rib w i t h o u t e v i d e n c e of p n e u mothorax. In t h e r a d i o l o g y d e p a r t m e n t , t h e p a t i e n t w a s u n a b l e to lie fiat on t h e t a b l e for t h e CT s t u d y b e c a u s e of a d r a m a t i c i n c r e a s e in a b d o m i n a l p a i n . T h e CT s c a n w a s c o m p l e t e d a f t e r t h e p a t i e n t received meperidine. The scan showed a severe r i g h t r e n a l i n j u r y w i t h e x t e n s i v e e x t r a v a s a t i o n of contrast material into the renal parenchyma and extravasating outside the kidney. Bleeding was also n o t e d in t h e r e n a l c o n a l f a s c i a on t h e r i g h t
A c o n t u s i o n w a s n o t e d on t h e right p o s t e r i o r axillary line. T h e r e w a s a l s o m a r k e d right c o s t o v e r t e b r a l a n g l e tenderness.
What do you suspect? Discussion T h e p a t i e n t w a s t a k e n i m m e d i a t e l y to a n e x a m i n a tion r o o m a n d c a r d i a c m o n i t o r i n g d e m o n s t r a t e d normal s i n u s r h y t h m . A n i n t r a v e n o u s c a t h e t e r w a s i n s e r t e d a n d a n infusion w a s started. L a b o r a t o r y specimens were obtained, including a complete blood cell c o u n t a n d d e t e r m i n a t i o n of s e r u m a m y l a s e c o n c e n t r a t i o n s a n d electrolyte levels. The patient vomited twice and reported worseni n g of a b d o m i n a l p a i n while w a i t i n g for a c o m p u t e d t o m o g r a p h i c (CT) s c a n to b e a r r a n g e d . H e r h e m o Jacqueline Mador is a staff nurse, Emergency Department, Southern Maine Medical Center, Biddeford, Maine. Reprints not available from author. J Emerg Nurs 1996;22:358-9. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/1/73647
358
Volume 22, Number 4
s i d e . T h e r e w a s n o e v i d e n c e of u r e t e r a l a v u l s i o n , or i n t r a p e r i t o n e a l or r e t r o p e r i t o n e a ] h e m o r r h a g e . I n j u r y to t h e k i d n e y , e s p e c i a l l y in c h i l d r e n , is a c o m m o n result of b l u n t t r a u m a . A l m o s t 80% of all r e n a l injuries in c h i l d r e n are r e l a t e d to b l u n t trauma. Children's proportionally larger kidneys, weaker a b d o m i n a l m u s c l e s , m o r e flexible rib c a g e s , a n d less p e r i r e n a l fat all c o n t r i b u t e to r e n d e r t h e m m o r e s u s c e p t i b l e to renal injury. A child w i t h a renal injury m a y h a v e no s y m p t o m s or m a y report a b d o m i n a l pain. A l t h o u g h h e m a t u r i a is a c o m m o n finding a n d occurs in u p to 96% of all c a s e s of renal trauma, t h e r e is no correlation b e t w e e n t h e a m o u n t of h e m a t u r i a a n d t h e s e v e r i t y of the injury There m a y also b e a s s o c i a t e d flank pain, contusions, flank e c c h y m o s i s (known as Grey Turner's sign), periumbilical e c c h y m o s i s (known a s Cullen's sign), n a u sea, v o m i t i n g , a n d h e m o d y n a m i c instability.
Mador/JOURNAL OF EMERGENCYNURSING
T h e girl's h e m o d y n a m i c s t a t u s r e m a i n e d stable, as did h er h e m o g l o b i n a n d h e m a t o c r i t levels. Her c o n d i t i o n w a s m a n a g e d c o n s e r v a t i v e l y in t h e intens i v e c a r e u n i t w i t h i n t r a v e n o u s fluids a n d serial CT
The child's presentation warranted immediate evaluation, despite her normal signs and ambulatory status. In particular, the finding of pain w i t h history of bright red blood in the patient's urine s u g g e s t s significant injury. s c a n s . S h e w a s d i s c h a r g e d 9 d a y s later w i t h o u t significant complications.
T h e m e c h a n i s m of injury is clearly d e s c r i b e d in this case, b u t a c c i d e n t s i n v o l v i n g b i c y c l e s c a n easily result in straddle injuries, w h i c h m a y b e difficult to identify in a child. Straddle injuries c a n c a u s e large h e m a t o m a s a n d l a c e r a t i o n s of t h e p e r i n e u m . Girls m a y also e x p e r i e n c e v a g i n a l lacerations, p r o d u c i n g b r i g h t r ed blood at t h e p e r i n e u m w i t h an u n c l e a r source. I n t r a p e r i t o n e a l injury c a n also occur. T h e peri n e u m m u s t b e v i s u a l i z e d in a m o r e p r i v at e a r e a w h e n e v a l u a t i n g t h e relative a c u i t y of a straddle injury. Pelvic fractures m a y also p r o d u c e si g n s a n d s y m p t o m s similar to t h o s e d e s c r i b e d in this case. T h e possibility of pelvic fracture, w i t h c o n c o m i t a n t urethral damage, should be considered before catheterization attempts.
Suggested readings Allshouse M, Betts J. Genitourinary injury. In: Eichelberger M, editor. Pediatric trauma prevention, acute care, rehabilitation. St Louis: Mosby-Year Book, 1993:503-8. Gausche M. Genitourinary trauma. In: Barkin R, editor. Pediatric emergency medicine, concepts and clinical practice. St Louis: Mosby-Year Book, 1992:292-7.
Section editor's teaching points T h e child's p r e s e n t a t i o n w a r r a n t e d i m m e d i a t e evaluation, d e s p i t e her n o r m a l vital s i g n s a n d a m b u l a t o r y status. In particular, t h e f i n d i n g of p a i n w i t h history of b r i g h t red blood in t h e p a t i e n t ' s u r in e s u g g e s t s sign i f i c a n t injury.
Contributions f o r this column shouM be sent to Lisa Molitor, ARNP, MSN, CEN, CCRN, 8404 S.W. 28th Place, Gainesville, FL 32607. phone (904) 331-1781.
AVAILABILITY OF Journal BACK ISSUES As a service to our subscribers, copies of back issues of Journal of Emergency Nursing for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted at a cost of $9.00 per issue. The following quantity discounts are available: 25% off on quantities of 12 to 23, and one third off on quantities of 24 or mare. Please write to Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Dr., St. Louis, Me 63146-3318, or call (800) 453-4351 or (314) 4534351 for information on the availability of particular issues. If unavailable from the publisher, photocopies of complete issues may be purchased from UMI, 300 N. Zeeb Rd., Ann Arbor, MI 48106; (313) 761-4700.
August 1996 359