From the Guidelines
The most appropriate next step in diagnosis for this 11-year-old boy is a CT scan of the abdomen with contrast (option A). This patient presents with signs of significant trauma including right lower chest and flank pain, gross hematuria, and fractures of the 12th rib and L1 spinous process following a bicycle accident. The combination of flank pain, hematuria, and rib fractures strongly suggests a renal injury, which is common in children with this mechanism of trauma 1. A CT scan with contrast would provide detailed images of the kidneys, ureters, and bladder to assess the extent of urinary tract injury, which appears likely given the gross hematuria. It would also evaluate for other potential intra-abdominal injuries that might not be apparent on physical examination. The patient's vital signs are stable, but the significant hematuria warrants immediate imaging rather than observation. Renal angiography is too invasive as a first-line test, testicular Doppler is not indicated without signs of testicular trauma, and voiding cystourethrography would not adequately evaluate the upper urinary tract where injury is most likely based on the clinical presentation. According to the guidelines, pediatric patients with high energy/penetrating/decelerating trauma and/or in cases of drop in hematocrit associated with any degree of hematuria should undergo contrast-enhanced CT-scan with delayed urographic phase 1. In this case, the patient's mechanism of injury, physical findings, and gross hematuria justify the use of a CT scan with contrast as the next step in diagnosis. The CT scan will help identify the extent of the renal injury and guide further management, which may include non-operative management or surgical intervention depending on the severity of the injury 1. Therefore, a CT scan of the abdomen with contrast is the most appropriate next step in the diagnosis and management of this patient.
From the Research
Diagnosis of the Patient's Condition
The patient presents with moderate right lower chest pain, severe right flank pain, and "threadlike" bright red blood in his urine after a bicycle accident. The patient's symptoms and laboratory results, including the presence of too numerous to count RBCs in the urine, suggest a possible renal injury.
Possible Causes and Next Steps
- The patient's history of trauma and the presence of hematuria (blood in the urine) suggest a possible renal injury, such as a laceration or contusion of the kidney.
- The patient's fracture of the 12th rib and the spinous process of the first lumbar vertebra may also be contributing to the patient's pain and hematuria.
- A CT scan of the abdomen with contrast 2 would be the most appropriate next step in diagnosis, as it would allow for visualization of the kidneys and detection of any potential injuries, such as urinary extravasation.
- The optimal timing of the excretory phase of the CT scan is important for diagnosis of urinary extravasation, with a delay of 9 minutes between the early and excretory phases optimizing detection 2.
- The CT nephrogram can also provide important information about the patient's renal function and any potential structural abnormalities 3.
Ruling Out Other Conditions
- The patient's symptoms and laboratory results do not suggest deep vein thrombosis (DVT) as a primary concern, although it is a potential complication of trauma 4.
- The patient's symptoms and laboratory results also do not suggest acute appendicitis as a primary concern, although it is a possible cause of abdominal pain in children 5.
Next Steps in Management
- A CT scan of the abdomen with contrast is the most appropriate next step in diagnosis, given the patient's symptoms and laboratory results.
- The patient should be closely monitored for any signs of worsening condition, such as increasing pain, hematuria, or signs of shock.