abdominal trauma, renal injury, renal trauma

1. ABDOMINAL TRAUMA
Renal Trauma
Dr. M. Akram Chalid, Sp.B, M.Kes

7. Background
• 1-5% of all traumas
• Male to female ratio 3:1
• Mechanism is classified as blunt or
penetrating
• blunt trauma accounts 90-95%
• Traffic accidents accounts half of blunt
renal injuries
• Renal lacerations and renal vascular
injuries make up only 10-15% of blunt
renal injuries

8. Background
• Renal artery occlusion is associated with a
rapid deceleration injuries
• Rate of nephrectomy in recent wars is
relatively high (25-33%)

9. Injury Calssification
• A total of 26 classifications have been presented in
the literature in the past 50 years
• These are oriented to different criteria such as :
1. The pathogenesis ( blunt or penetrating )
2. The morphological findings ( type and degree of
lacerations )
3. The clinical course ( nature and time of symptoms )

10. AAST renal injury grading scale
Grade Description of injury
1 Contusion or non-expanding subcapsular hematoma
No laceration
2 Non-expanding perirenal hematoma
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration > 1cm without urinary extravasation
4 Laceration : through corticomedullary junction in to collecting system
Or
Vascular : segmental renal artery or vein injury with contained hematoma
5 Laceration: shatered kidney
Or
Vascular : renal pedicle injury or avulsion

13. Initial emergency assessment
• Securing of the airway
• Controlling any of the external bleeding
• Resuscitation of shock
• Physical examination is carried out during
stabilization

14. History and physical examination
• Direct history is obtained from conscious
patients
• Witness and emergency personnel can
provide information regarding unconscious
patients

15. Possible indicators of major renal injury

16. The following findings on physical
examination may indicate possible renal
involvement :
1. Hematuria
2. Flank pain
3. Flank ecchymosis
4. Flank abraisions
5. Fractured ribs
6. Abdominal distension
7. Abdominal mass
8. Abdominal tenderness

17. Guidelines on laboratory evaluation
• Urine from a patient with suspected renal injury
should be inspected grossly and then by dipstick
analysis
• Serial hematocrit measurement indicates blood
loss ( renal or associated injuries ? )
• Creatinine measurement reflects renal function
preior to the injury

18. Guidelines on radiographic assessment
• Blunt trauma patients with macroscopic or microscopic
hematuria ( at least 5 rbc/hpf ) with hypotension (systolic
blood pressure < 90 mmHg ) should undergo
radiographic evaluation
• Radiographic evaluation is also recommended for all
patients with a history of rapid deceleration injury and /or
significant associated injury
• All patients with any degree of hematuria after
penetrating abdominal or thoracic injury require urgent
renal imaging
• Ultrasonography can be informaive during the primary
evaluation of polytrauma patients and for the follow-up
of the recuperating patients

19. Guidelines on radiographic assessment
• A CT scan with enhancement of intravenous contrast material is the
best imaging study for diagnosis and staging renal injuries in
hemodynamically stable patients
• Unstable patients who require emergency surgical exploration should
undergo a one-shot IVP with bolus intravenous injection of 2ml/kg
contrast
• Formal IVP , MRI , and radiographic scintigraphy are reliable alternative
methods of imaging renal trauma when CT is not available
• Angiography can be used for diagnosis and simultaneous selective
embolization of bleeding vessels

21. Treatment
• Non-operative management is the
treatment of choice for the majority of renal
injuries
• The overall exploration rate for blunt
trauma is less than 10%
• The overall rate of patients who have a
nephrectomy during exploration is around
13%

22. Guidelines on management of renal trauma
• Stable patients following grade 1-4 blunt renal
trauma , should be managed conservatively :
Bed-rest , hydration and antibiotics , and
continuous monitoring of vita signs until
hematuria resolves
• Stable patients , following grade 1-3 stab and low
velocity-gunshot wounds after complete staging ,
should be selected for expectant management

23. Guidelines on management of renal trauma
• Indications for surgical management include :
1. Haemodynamic instability
2. Exploration for associated injuries
3. Expanding or pulsatile perirenal hematoma identified during
laparotomy
4. A grade V injury
5. Incidental finding of pre-existing renal pathology requiring surgical
therapy
Renal reconstruction should be attempted in cases where the primary goal of
controlling hemorrhage is achieved and sufficient amount of renal
parenchyma is viable

24. Guidelines on post-operative management and
follow-up
• Repeat imaging is recommended for all hospitalized patients within 2-4 days
following renal trauma
• Nuclear scintigraphy before discharge from the hospital is useful for
documenting functional recovery
• Within 3 months of major renal trauma , patients follow-up should involve :
1. Physical examination
2. Urinalysis
3. Individualized radiological investigation
4. Serial blood pressure measurement
5. Serum determination of renal function
• Long-term follow-up should be decided on a case-by-case basis

27. Complications
• Early complications :
Bleeding , infection , perinephric abscess , sepsis ,
urinary fistula , hypertension , urinary extravasation and
urinoma
• Delayed complications :
Bleeding , hydronephrosis , calculus formation , chronic
pyelonephritis , hypertension , arteriovenous fistula , and
psuedoaneurism

28. Guidelines on management of complications
• Complication following renal trauma require a
thorough radiographic evaluation
• Medical management and minimal invasive
techniques should be the first choice for the
management of complications
• Renal salvage should be the aim of surgeon for
patients in whom surgical intervention is
necessary

30. Guidelines on management of polytrauma patients
with associated renal injury
• Polytrauma patients with associated renal
injuries should be evaluated on the basis of the
most threatening injury
• In cases where the decision for surgical
intervention is made , all associated injuries
should be evaluated simultaneously
• The decision for conservative management
should regard all injuries independently