Trauma Flashcards
What is the incidence of urinary tract trauma?
10%
How common is renal trauma?
1-5% of all trauma
What is the male to female ratio when it comes to urogenital trauma?
3:1
How effective are airbags when it comes to renal trauma?
decreases renal injuries by 40-50%
How common is renal vasculary injury in renal trauma?
<5%
What are the indication for imaging in renal trauma?
Blunt trauma:
gross hematuria
microhematuria + hypotension
rapid desceleration injuries
Penetrating trauma:
all with hematuria
clinical suspicion (inlet or exit wound)
What laboratory tests should be performed on a patient who has suffered renal trauma?
Urine
Hematocrit
Creatinine (8 hrs before change can be measured)
When should on shot intraoperative IVP be used?
In those, unstable, subjected to laparotomy
to see the condition of the contralateral kidney
2 ml/kg contrast, single x-ray after 10 min
What is importernt to remember when performing a CT on a patient with a suspected urinary tract injury?
2 phase study
both a vascular phase and a
delayed phase afte 10 min to look for peri-renal or ureteral contrast extravasation
When should you use an MRI to evaluate a patient with suspected urinary tract injury?
CT is not availabel
Iodine allergy
CT findings are equivocal
When is angiography indicated for a patient with suspected urinary tract injury?
stable patient when therapeutic angio-embolization is needed
or
non enhanced cortex on CT-scan (suspection of total avulsion, renal artery thrombosis or severe concussion causing vascular spasm)
Renal score AAST Grade 1:
contusion or subcapsular hematoma
Renal score AAST Grade 2:
Cortical laceration <1 cm no extra-vasation
Renal score AAST Grade 3:
Cortical laceration >1 cm no extra-vasation
Renal score AAST Grade 4:
Laceration > 1cm with injury to the collecting system
and/or
Thrombosed artery or segmental vein injury
Renal score AAST Grade 5:
Shattered kidney
and/or
Renal pedicle avulsion
Indication for renal exploration:
continues hemodyamic instability (in spite of resuscitation)
expanding retroperitoneal hematoma
pre-existing abnormality (hydronephrosis, tumour)
What is the treatment when PNL has caused trauma to the colon?
Liberal drainage of the PCS Keep the tube in the perinephric and pericolic spaces Antibiotics Stop oral feedings for 5 days Success rate is very high
What is the most common cause of ureteral trauma?
Iatrogenic 75%
blunt 18%
penetrating 7%
What type of iatrogenic trauma is most common?
Gynecologic 70%
General surgery 14%
Urology 16%
Ureteral trauma AAST Grade 1:
hematoma and/or contusion
Ureteral trauma AAST Grade 2:
laceration < 50% of circumference
Ureteral trauma AAST Grade 3:
laceration > 50% of circumference
Ureteral trauma AAST Grade 4:
complete tear < 2 cm loss
Ureteral trauma AAST Grade 5:
complete tear ≥ 2 cm loss
How often is an injury to the ureter overlooked?
60%
What can be symptoms that leads to a late diagnosis of ureteral injury?
Leakage Acute obstruction Sepsis Uro-ascites Urinoma Fistula
When should surgical repair of a urethral injury be undertaken?
Within one week
or
after 2-3 months
Examples of surgical techniques for re-continuity of urethers:
end to end anastomosis
Transuretero-ureterostomy
Uretero-calycostomy
Boari flap ± psoas hitch
Auto transplantation
Ileal segment interposition
What is the most common cause of bladder trauma?
70-80% due to pelvic fracture
Symptoms of bladder injury:
+ symptoms of silent rupture
Hematuria
Pain
No desire or inability to void
Urine leak and/or blood through the vagina
in silent rupture: ileus ascites peritonitis uremia sepsis toxemia
Bladder trauma AAST Grade 1:
concussion, intramural hematoma partial thickness
Bladder trauma AAST Grade 2:
extra peritoneal rupture < 2 cm
Bladder trauma AAST Grade 3:
extra peritoneal rupture > 2 cm or intra peritoneal rupture < 2 cm
Bladder trauma AAST Grade 4:
Intraperitoneal rupture ≥ 2 cm
Bladder trauma AAST Grade 5:
extra or intra peritoneal laceration extending into the bladder neck or trigone
Radiological diagnosis of bladder trauma:
Retrograde gravity cystography (also excludes urethral trauma)
CT can be used especially if other trauma is present
When is surgical repair indicated in bladder trauma?
Intraperitoneal rupture or extraperitoneal rupture when drainage is not guaranteed or surgery is indicated for other injuries
Postoperative care after surgical treatment of bladder injury:
Antibiotics
Catheter 10 days
Retrograde cystogram before catheter removal
(if leakage, catheter for another 5 days)
Penile trauma AAST Grade 1:
Cutaneous laceration or contusion
Penile trauma AAST Grade 2:
Laceration of Buck’s fascia (cavernosum) withour tissue loss
Penile trauma AAST Grade 3:
Cutaneous avulsion, laceration through glans or meatus
or cavernosal or urethral defect < 2cm
Penile trauma AAST Grade 4:
partial penectomy
or cavernosal or urethral defect ≥ 2 cm
Penile trauma AAST Grade 5:
total penectomy
What is the most common cause of posterior urethral trauma?
pelvic fracture
present i 4-14 % of pelvic fracture cases
males>females
How often is posterior urethral injury associated with bladder rupture?
10-17%
How common is urethro-rectal fistula after posterior urethral injury?
up to 8%
What clinical signs should arise suspicion of posterior urethral injury?
Blood at the meatus
Inability to urinate
Full bladder
Urethral injury AAST Grade 1:
Contusion: blood at the meatus
Urethral injury AAST Grade 2:
Stretch injury: elongation of the urethra without extravasation
Urethral injury AAST Grade 3:
Partial disruption: extravasation at injury site with bladder visualization
Urethral injury AAST Grade 4:
Complete disruption: Extravasation at the injury site without bladder visualization < 2 cm urethral separation
Urethral injury AAST Grade 5:
Complete disruption: Complete transection with ≥ 2 cm separation or extension to the prostate of vagina
How do you confirm an urethral injury?
Urethrography
What options are there when it comes to the timing of surgical treatment for an urethral injury?
Immediate: < 48H
Delayed: 2 days- 2 weeks
Deferred: > 3 months
How should a complete posterior urethral rupture be treated?
Immediate realignment (with catheter for 4-8 weeks)
then Deferred urethroplasty
sucessrate 80-98%
What are the most common complications from posterior urethral injuries?
Impotence
Incontinence
How should you treat Anterior Urethral Trauma?
Open repair over catheter alignment
or suprapubic tube without repair
What kind of trauma can cause Anterior Urethral injury?
Straddel injury
Sexual intercourse
Gunshots
Iatrogenic trauma
