AUAGL Trauma (2020) Flashcards
Imaging for trauma patient with gross or microscopic hematuria and SBP <90?
Difference between adults and children?
CT with contrast (get immediate and delayed images; don’t need non-con)
Children often will not exhibit hypotension (where an adult would).
Does a stable trauma patient with MoI or PE finding need imaging?
Yes. Get CT w/ contrast (immediate and delayed).
Rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest
Preferred imaging in suspected renal trauma?
CT + IV contrast
Need immediate + delayed images. Don’t need non-con phase for trauma.
Preferred management strategy for stable renal trauma patients?
If no s/s shock and stable serial hgb then preferred strategy is noninvasive management.
Noninvasive management includes close hemodynamic monitoring, bed rest, ICU admission and blood transfusion.
Avoids unnecessary nephrectomy and preserves renal function.
In hemodynamically UNSTABLE patients not responding to resuscitation, what do you do next?
IMMEDIATE INTERVENTION
OR exploration or angioembolization by IR
Imaging findings that direct you intervene immediately (thus prior to resuscitation attempts)
Large perirenal hematoima (>4 cm)
Vascular contrast extravasation in the setting of deep or complex renal laceration (AAST grade 3-5)
Immediate intervention means either open exploration or IR embolization
Stable patient with renal parenchymal injury + urinary extravasation– what may you do?
You can initially observe the stable patient with renal injury
Excluded from this would be patient with renal pelvis or proximal ureteral injuries.
Imaging findings suggestive of renal pelvis or proximal ureteral injury?
- Large medial urinoma
2. Contrast extravasation on delayed images without distal ureteral contrast
Who needs follow up imaging with renal trauma?
You need to reimage 48 hours later.
- Deep renal laceration (AAST grade 4-5)
- Clinical signs of complications (fever, ongoing blood loss, abd distension, worsening flank pain)
Uncomplicated, low grade (AAST 1-3) do not routinely need repeat imaging.
When do you need to perform urinary drainage for renal trauma?
In the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula, infection.
Can use ureteral stent, PCN, or perc drain (into the urinoma)… or a combo or 2 or all 3!
Absolute indications for open exploration in context of renal trauma?
Expanding/pulsatile hematoma, hemodynamic instability, suspected renal pedicle avulsion, and UPJ disruption
Use transabdominal approach, rather than flank.
What do you do for a STABLE trauma patient with suspected ureteral injury?
CT A/P with contrast and delayed images (10-minutes) (don’t need non-contrast)
Suspected ureteral injury in trauma patient who went directly to OR for laparotomy without imaging?
Urologist should directly inspect the ureter
If findings equivocal can do retrograde pyelogram or inject methylene blue.
MUST, SHOULD, MAY ???
Surgeons ______ repair traumatic ureteral lacerations at the time of laparotomy in stable patients.
SHOULD
Managing ureteral injury in the UNSTABLE patient during laparotomy?
Options:
Tie off the ureter, PCN for urinary drainage, delayed repair.
Externalized ureteral stent tied off at the level of proximal ureteral defect.
How to manage ureteral contusion identified at time of laparotomy?
Attempt ureteral stent placement
Also in select cases can do resection of contused/injured ureteral segment and primary repair (UU)
Ureteral injury and stent placement is either unsuccessful or impossible?
Next step is PCN (duh)
Management of ureterovaginal fistula?
Initially attempt management with ureteral stent. If fails then surgical management (usually ureteral reimplantation, but all of the techniques possibly apply here depending on exact injury).
Management of ureteral injury proximal to iliac vessels?
Should perform primary repair (spatulated, tension free repair over a stent).
Management of ureteral injury distal to iliac vessels?
Manage with primary repair (UU) or ureteral reimplantation.
Primary repair only if segments seem healthy. If concern for ureteral viability, resect and just do reimplant.
Autotransplantation or bowel segment interposition are never the answer in the acute setting. If injury is this bad then tie off ureter proximally, get PCN, and delayed repair.
Management of endoscopic ureteral injuries?
Ureteral stent or PCN, as able.
If urinary diversion fails, then use surgical repair technique depending on the location/severity of the ureteral injury.
What to do in stable patient with gross hematuria and pelvic fracture?
MUST perform cystogram (either plain or CT is acceptable)
Aim for 300ml bladder volume for max fill.
In addition to GH + pelvic fx, what other scenario warrants cystogram?
GH + mechanism of injury that is concerning
Other clinical signs of bladder injury can warrant imaging (inability to void, elevated BUN and Cr, abd distension, low UOP, SP pain)
Management of intraperitoneal bladder injuries?
MUST perform surgical repair for intraperitoneal injuries in the context of both blunt and penetrating external trauma.
