Renal Trauma Trevor Flashcards
Why are children more susceptible to trauma-based kidney injuries?
Children have larger overalls kidneys compared to body size
Children have less perirenal fat
Lower ribs are incompletely ossified
What is the most common cause of genitourinary trauma?
Blunt force trauma
degree of hematuria does not correlate with degree of injury
Structures in upper and lower urinary tracts
Upper tract:
- kidneys
- ureters
Lower tract:
- bladder
- urethra
- genitalia
Why should you check the urethral meatus during pelvic trauma?
If there is blood in the urethral meatus, you need to be careful placing a folly catheter since you could cause more damage to a urethral injury
Are ureters likely to be damaged in blunt trauma?
NO they are well protected
- most is penetrating trauma
What is the most common cause of damage to the bladder?
Blunt trauma and pelvic fractures
Bladder is only likely to rupture if the bladder is full and there is injury to the lower abdomen
Why is the male urethra more prone to injury
It’s long and less mobile compared to the female
Urethrogram/cystogram
Injecting contrast material into the distal urethra to check injury of the urethra and/or bladder
- leakage or improper filling of the bladder can indicate urethral injury
Indications for retrograde urethrogram (RUG)
Patient unable to void after pelvic trauma
Physical exam signs concerning for urethral injury
Blood at urethral meatus
Scrotal hematoma
Ecchymoses of perineum
Prostate displacement on rectal exam
How to treat generalized uncomplicated lower tract renal injuries?
Extraperitoneal injuries = Foley catheter and time
- just manage, nothing invasive
Intraperitioneal injuries = ** need surgery
What is the imaging study of choice for the upper urinary tract?
#1 = CT scan of the abdomen and pelvis with IV contrast - IVP is 2nd choice
cystogram is lower urinary tract
What is the definitive treatment for pelvis fractures with hemorrhage?
Pelvic placement via a pelvic cast
Also requires massive transfusion protocol with > 10 units of packed RBCs and both platelets andFPP at a ratio of 1:1:1
this differs from osteoporosis adults
When to decide to give packed RBCs?
Either:
1) Hemoglobin is <7 but is a euvolemic non trauma patient
2) Ongoing severe hemorrhage and unstable vital signs
type O- blood is the universal donor blood, type AB plasma is the universal donor plasma
1 unit of pRBC = increases Hgb by 1 g/dL or Hct by 3%
What is the typical transfusion rate for stable patients?
typical = 1 unit of pRBCs over 2 hrs
Level 1 rapid transfusion = 500ml/min
FFP vs Prothrombin complex concentrate (PCC)
PCC = contains Vitamin-K factors 2/7/9/10
- FFP does not have this
**FFP also has higher Volume than PCC which can be problematic in patients with edema/CHF
PCC is way more expensive (5000) than FFP (250)
What are counts to remember for platelet transfusions
<10,000 = give platelets everytime as prophylaxis
Major surgery and is 50,000 = give platelets
Active hemorrhage >50,000
CNS injuries >100,000
even though its still used, if the patient has ITP or TTP the platelets and transfusions will be destroyed
Tranexamic acid (TXA)
1 in noncompressible hemorrhages or heavy uterine bleeding
MOA: inhibits binding sites on plasminogen which prevents the breakdown of plasminogen -> plasmin
essentially the opposite of tPA
Does the amount of blood from a urinary injury directly correlate with the degree of severity?
NO
When do you give FFP to a patient?
Hemorrhaging patient with a coagulopathy present
- requires type and screen to be ABO compatible
also need to monitor PT/PTT
TRALI
Transfusion related acute lung injuries
- 1:5000 incidence in patients who have transfused blood products
Caused by neutrophils being sequestered in the micro vasculature of the lungs and then activation of the neutrophils causes releases of cytokines and ROS which damages pulmonary capillary endothelium
Symptoms: “all occur within 6hrs of transfusion”
- hypoxemia
- fever
- hypotension**
- cyanosis
- respiratory distress
TACO
Transfusion associated circulatory overload
- presents as a reaction to blood transfusions that develops Pulmonary edema due to volume overload
- high risk in patients with underlying cardiovascular or renal diseases
Symptoms: “all present within 6-12hrs after infusion”
- respiratory distress
- Hypertension**
- headaches
- seizures (rare)
- wide pulse pressure
- S3 heart sound on auscultations
- wheezes/rales on auscultation
Evaluation of direct kidney trauma
CT scan w/ IV contrast = #1
Most dont require surgical intervention and just require outpatient (grade 1-2) or admission (grade 3) with symptomatic and palliative care
if a grade 4 or 5 with devascularization of the kidney or grade 1-3 with persistence of urine leakage = needs surgery
Should digital rectal exams be used to diagnosis urethral or prostate injuries?
NO
- often times the prostate cant be felt properly due to pelvic hematomas (which are common in these injuries)
digital recital exams should be focused solely on detecting rectal injuries
What are common complications of urethral injuries?
Urethral strictures
Urinary incontinence
Erectile dysfunction (from either neurogenic or vasogenic)
What are the 4 views of a fast exam?
Right upper quadrant = Morrison’s pouch
Left upper quadrant = splenomegaly recess
Subxiphoid = looking for hemopericardium
Pelvic = rectovesical/rectouterine pouch
Treatment of spleen injuries
If hemodynamically stable with grade 1-3 spleen injuries (no vasculature damage)
- if hemodynamically unstable or grade 4 is present = splenectomy
Avoid splenectomy if possible!!
