renal trauma by mohammad shaar,m.d

8/12/2019 Renal Trauma by Mohammad Shaar,M.D.

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Renal Trauma



Background

Renal trauma occurs in approximately 1-5% of all trauma cases

The Kidney is the most commonly

injured genitourinary and abdominalorgan

Male to Female ratio 3:1

Renal trauma can be acutely life-threatening, but the majority of renal

injuries are mild and can be managed

conservatively



Mechanismof the injury

Blunt Penetrating



Blunt Trauma

Secondary to motor vehicle accidents, falls,vehicle-associated pedestrian accidents,

contact sport and assaults

Traffic accidents are responsible for morethan 50% of blunt renal injuries



Renal laceration and renal vascularinjuries make up only 10-15% of all blunt

renal injuries

Isolated renal artery injury followingblunt abdominal trauma is extremely

rare and make about 0.1% of all trauma

patients Renal artery occlusion is associated with

rapid deceleration injuries.



Penetrating Trauma

Gunshot and stab wounds represent themost common cause of this type of

trauma

Penetrating injuries tend to be moresevere and less predictable than blunt

ones

Gunshot usually associated with multipleorgans injuries



AAST Classification



Grade I

Contusion or

nonexpanding

subcapsular

hematoma, nolaceration.



Grade II

Non expanding

perirenal Hematoma

Cortical laceration <

1 cm deep withoutextravasation



Grade III

Cortical laceration >

1cm without urinary

extravasation



Grade IV

Laceration: through

corticomedullary

junction into collectingsystem

Or

Vascular: Segmentalrenal artery or vein

injury with contained

hematoma or partial

vessel laceration or



Grade V

Laceration :shattered kidney

Or

Vascular : Renalpedicle avulsion



AAST Classification

Grade Description of injury

IContusion or nonexpanding subcapsular hematoma, no

laceration.

II Non expanding perirenal HematomaCortical laceration < 1 cm deep without extravasation

III Cortical laceration > 1cm without urinary extravasation

IV

Laceration: through corticomedullary junction into collecting

systemOr

Vascular: Segmental renal artery or vein injury with

contained hematoma or partial vessel laceration or vessel

thrombosis

VLaceration : shattered kidneyOr



Diagnosis



History

A direct history is obtained fromconscious patients witnesses and

emergency personnel can provide

valuable information about unconsciousor seriously injured patients

Pre-existing renal abnormality makes

renal injury more likely following trauma. Trauma patients with Horseshoe kidney

are at risk of losing all functioning renal

tissue



Physical Examination

Vital signs should be recordedthroughout diagnostic evaluation

Hemodynamic stability is the primary

criterion for the management of all renalinjuries

In stab wounds, the extent of entrance

wound will not accurately reflect thedepth of the penetration



The following findings on physical examination

could indicate possible renal involvement:

• haematuria

• flank pain

• flank ecchymoses

• flank abrasions

• abdominal

distension

• abdominal

tenderness

• abdominal mass

• fractured ribs



Laboratory Evaluation

The trauma patient is evaluated by aseries of laboratory tests, the most

important tests for evaluating renal

trauma are:• Urinalysis

• Hematocrit

• Baseline Creatinine



Urinalysis

The basic test in the evaluation ofpatient with suspected renal trauma

Haematuria is the first indicator of renal

injury Neither sensitive nor specific enough to

differentiate minor and major injuries

Disruption of the UPJ , renal pedicleinjuries or arterial thrombosis may occur

without Haematuria

9% of proven stab wound Renal injury



Hematocrit

Initial Hematocrit associated with vitalsigns indicates the need for emergency

resuscitation

The decrease in Hematocrit andrequirement for blood transfusion are

indirect sign of the rate of blood loss



Creatinine

An increased Creatinine reflects usuallypreexisting renal pathology



Imaging

There is mounting evidence thatfollowing blunt trauma, some patients do

not require radiographic evaluation:

Patient with microscopic haematuria andno shock after a blunt trauma have a low

likelihood of developing renal injury



Indications for imaging are:

1. Gross haematuria

2. Microscopic haematuria and shock

3. presence of major associated injuries

4. rapid deceleration injury

5. penetrating trauma with kidney

involvement suspecting



Ultrasosgraphy (US)

popular, quick, non-invasive, low-costwithout exposure to radiation

Technical difficulty in multi-traumatic

patient Results highly depends on the operator

Can detect laceration but cannot

evaluate the depth nor extent Cannot give functional information



Difficulty in differentiating shatteredkidney from congenitally absent kidney

More sensitive than IVP in minor blunt

trauma Decreased sensitivity when the severity

of the injury increases



Standard Intravenous Pyelography

(IVP)

Was the preferred imaging methodbefore the CT

Presence or absence of one or the two

kidneys Defines the parenchyma

Outlines the collecting system

The most significant finding on the IVPare : nonfunctional and extravasation

Sensitivity is >92% for all degrees of

severity



One-Shot Intraoperative Intravenous

Pyelography (One-Shot IVP)

Unstable patients who are unstable toundergo CT

The technique consists of a bolus

intravenous injection of 2mL/kg ofradiographic contrast followed by a

single plain film taken after 10 minutes

Important information for decisionmaking

Studies showed not that good sensitivity

in penetrating trauma



Magnetic Resonance Imaging

(MRI)

MRI can replace CT when:

1. CT is not available

2. Iodine allergy

3. Ct findings are equivocal



Angiography

The most common indication forarteriography is non-visualization of a

kidney on IVP after major blunt renal

trauma when a CT is not available



Common causes for non-visualization

are:

Total avulsion of the renalvessels (usually presents with

life-threatening bleeding)

Renal artery thrombosis Severe contusion causing

major vascular spasm.



Treatment



Approaching Unstable Trauma

(penetrating or blunt)

Suspected adult renaltrauma

Unstable

Emergency laparotomyOne-shot IVP

Abnormal IVP

Renal Exploration

Normal IVP

Retroperitonealhematoma

Pulsatile orexpanding

Stable Observation

A hi St bl Bl t



Approaching Stable Blunt

TraumaSuspected adult blunt

renal trauma

Stable

GrossHaematuria

RenalImaging

Grade3-4

Observation

Bed rest

HCT

Antibiotics

Associatedinjuriesrequire

laparotomy

Grade5

Renalexploration

Grade 1-2

Microscopic

Haematuria

Rapiddeclaration injury or

majorassociated

injuries

Observation



Approaching Stable Penetrating

Trauma

Suspected Adult Penetrating Renal Trauma

Stable

Renal Imaging

Grade 3

Observation

Bed Rest

HCT

antibiotics

Associatedinjuries requiring

laparotomy

Grade 4-5

RenalExploration

Grade 1-2

Observation



Complications

Delayed complications

:

Bleeding

Hydronephrosis

Calculus

Hypertension

Chronic pyelonephritis

Arteriovenous fistula

Pseudoaneurysms

Early complications :

Bleeding

Infections

Peri-nephric abscess

Urinary fistula

Hypertension (acute-

chronic) Urinoma (

extravasation )

renal trauma by mohammad shaar,m.d

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