Trauma Flashcards
i )Most common mechanism of renal trauma
ii) Does haematuria indicate severity of renal injury?
i) Blunt - 80%
ii) No
- 13% penetrating renal truama have no haematuria
- 12.5% of patients with multisystem trauma have confirmed renal trauma
History taking / Examination in renal trauma
History:
i) Mechanism, Time-Line
ii) pre-existing renal abnormalities
Examination:
i) haematuria, Flank pain/tenderness
ii) Ecchymosis
iii) Ribfractures
When to image in suspected renal trauma
i) VH (In Paeds - NVH also)
ii) NVH and
SBP< 90mmHg/ OR Major associated injuries
iii) Mechanism - Rapid Deceleration, Hihglikelihood, Pentrating abdominal/torso trauma
Imaging in renal trauma:
i) Gold Standard
ii) Unstable going to laparotomy?
i) CT Triple Phase with Delayed Phase (Urographic)
ii) One shot IVU (2 ml/kg contrast and then single film after 10 mins)
What do the following indicate in context of renal trauma:
i) Lack of contrast enhancement
ii) Haematoma medial to kidney / Displacing vasculature
i) Pedicle Injury
ii) Renal Vein Injury
AAST Classification of renal Trauma
1 - Bruse
2 - Small Cut
3 - Big Cut
4 - Wet Cut
5 - Shattered
Management:
i) Grade 1-4 Blunt/ Grade 1-3 Penetrating Stable
ii) HD Unstable, Grade V Renal Injury
iii) Expanding / Pulsatile Haematoma at time of of laparotomy
iv) Solitary Injury with contrast extravasation
v) Bilateral Grade 4-5 Injury
vi) Solitary Kidney Renal Artery Injury
i) Conservative - Antibiotics, Bedrest, Monitoring
ii) Intervention - SAE, Repeat SAE, Before Surgical Exploration
iii) Exploration -> Renoraphy/ Repair / Laparotomy
iv) Can manage conservatively. >90% Extravasation Spontaneously resolved.
v) Consider Renal Artery Repair
vi) Consider Renal Artery Repair
What is the incidence of nephrectomy if surgical exploration is chosen?
75%
Can you embolise the main renal artery?
Yes:
- Can be definitive procedure if not suitable for surgery
- Can be a bridge to interval nephrectomy
Surgical Approach for Emergency Nephrectomy
Ideally Transperitoneal
- Control pedicle before exploring haematoma
- Retropertioneal incision over aorta superior to IMA OR Incision can be made medial to IMV
Indications for SAE
Active Haemorrhace
Pseudoaneurysm
AV Fistula
FU after conservative management of renal trauma
Major Injuries require FU
i) Repeat Imaging (2-4 days)
ii) 3 months - Renogram (Functional Recovery), Creatinine, BP (renovascular HTN)
Causes of iatrogen ureteric injury
Suture - Ligation/Kinking
Crushing - Clamps
Transection
Thermal Injury
Ischaemia due to devasuclarisation
Ix for iatrogenic ureteric injury
Intraop:
Cystoscopy + RGS
Direct Visualisation
IV Methylene Blue
Post-Op:
CTU
Cystoscopy/EUA/RGS
Classification of ureteric trauma
Mx
Surgical Technique
AAST Classification:
1 - Haematoma
2 - Laceration <50%
3 - Laceration >50%
IV - Complete tear <2cm
V - Complete Tear >2cm
Mx:
I-II - Stent
II - III - Stent + Primary Closure
III-IV - Stent/Reconstruction
Proximal : Uretero-Ureterostomy/ Ureterocalycstostomy
Middle - Uretero-Ureterostomy/Boari Flap/Transureteroureterostomy
Distal - Psoas Hitch/Reimplantation/Transureteroureterostomy
Complete - Ilieal Interposition/ Autotransplantation
Re-stenosis rate / Revision Rate post ureteric reconstruction
Stenosis rate - 4%
Revision - 10%
Bladder Trauma:
History
Exam
Ix
History - Trauma, Pelvic Fracture, Penetrating Injuries (?Other organs involved)
Exam - Low abdominal tenderness/distension/low UO
Ix - Cystogram/ CT Cystogram
Evidence of intraoperative bladder injury
Laparoscopy - Blood/gas in catheter bag
Cystoscopic:
- Dark space between detrussor fibres, Bladder not distending, Irrigation fluid not returning,
Investigations for suspected bladder injury
Cystogram ( 350 ml of contrast)
- Need AP/Oblique and post-drainage film
Cystoscopy
Types of bladder injury
Extraperitoneal (60%)
- Ax with pelvic fracture, Urine extravasation confined to perivesical space
Intraperitoneal (30%)
- Blunt trauma to full bladdder, Urine extravasation into peritoneal cavity
10% have combined injury
Classification of bladder injury
1 - Hamatoma/ Partial Thickness LAceration
2- EP Laceration <2cm
3 - EP Laceration >2cm or IP laceration <2cm
4 - IP Laceration >2cm
5- Laceration extending to bladde neck or ureteric orifice
Mx of:
EP Bladder Injury
IP Bladder Injury
EP
Conservative -2/52 catheter + Abx
Surgical if:
- Open Pelvis Fracture, Bone in bladder, Other pelvic visceral injury, Penetrating injury, BN Injury, Failed Conservative management
IP
TP Repair + Either urethra/SPC afterward
If small defect then catheter and monitor
Testicular Trauma - when to manage:
Conservatively
Surgically
i) Conservative:
Tunica Intact, Haematocele <3 times that of testis, Small intratesticular haematoma
Mx - NSAIDS + Scrotal Support
ii) Surgical:
Tunica disrupted, Dx uncertainty, Large/Expanding haematoma, Penetrating injury, degloving injury, testicular dislocation
Mx - Remove devitalised tissue and close tunica, Orchidectomy if shattered/infarcted, Fixation if testicular dislocation
Mx of Zipper Injury
Children GA/ Adult LA
Divide median bar of zipper - seperate faceplates
