This document discusses genitourinary trauma, focusing on renal trauma. It notes that the kidney is the most commonly injured genitourinary organ. Renal trauma is most often blunt, with severe cases associated with injuries to other organs. CT scan is the preferred imaging modality to evaluate renal injuries according to the American Association for the Surgery of Trauma classification system, which grades injuries from I to V based on severity. Grade I injuries involve contusions or small lacerations without urine extravasation. Grade II injuries include larger lacerations or hematomas confined to the kidney. Grade III injuries involve deeper lacerations or vascular injuries with contained bleeding.
Bosniak Classification and Renal Cystic Disease
" from both urological and radiological points of view "
historical point of view , uses and diagnostic significance , accuracy , all of these points and more in this presentation :)
Bosniak Classification and Renal Cystic Disease
" from both urological and radiological points of view "
historical point of view , uses and diagnostic significance , accuracy , all of these points and more in this presentation :)
Imaging abdomen trauma renal part 5 Dr Ahmed EsawyAHMED ESAWY
Imaging abdomen trauma renal part 5 dr ahmed esawy
include different cases for oral radiodiagnosis examination all over the world
CT /MRI Plain X ray images
blunt abdominal trauma
penetrating abdominal trauma
fast abdominal ultrasound
haemoperitoneum
pneumoperitoneum
american association of surgeon in trauma AAST
SUBCAPSULAR HAEMATOMA
PARENCHYMAL LACERATION
RENAL CONTUSION
RENAL LACERATION
KIDNEY SUBCAPSULAR HAEMATOMA
SHUTTER KIDNEY
RENAL INFARCTION
PERIRENAL FASCIA
PERIRENAL HAEMATOMA
RETROPERITONEUM AIR
Please find the power point on Urinary Tract Injury (Kidney Injury). I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. Renal Trauma
90% - Blunt, 10%-Penetrating
~10% of patients with significant
abdominal trauma.
When severe, associated with
injuries to other organs in upto 80%.
when the kidney is the only organ
damaged the injury is minor in
around 98% of cases
4. Mechanism of renal trauma
• Blunt trauma: direct blow to the kidney.
• Penetrating trauma: stab or gunshot injury.
• High-velocity deceleration: pedicle injury (avulsion of renal vessels,
thrombosis of renal artery).
Major renal injury(grade 4 and 5):
- up to 25% of blunt, and in up to 70% of penetrating renal trauma
cases.
6. Indications for renal imaging
• Penetrating
• Gross hematuria
• Microhematuria & Systolic BP<90 mmHg
• Pediatric:>50 rbc/hpf
• Mechanism of injury:
- Flank impact
- Deceleration injury (eg-fall from great height)
7. Indications( ..contd)
• Penetrating
-1/2 have grade 3,4 or 5 injuries.
- high index of suspicion if wounds to chest, flank or abdomen
• Adult Blunt : Degree of hematuria and SBP
- gross hematuria or microscopic +sBP<90mmHg(12.5 % major
injury)
-microhematuria+sBP>90mmHg(0.2%major injury)
• Paediatric Blunt:
-BP not reliable in children because hypotension is a late
manifestation of hypovolaemia.
-50 RBCs/hpf threshold.
8. Role of radiology
• Most contemporary trends in trauma care, including renal trauma,
• call for less invasive procedures, trauma imaging by a skilled
radiologist is important.
• Accurately distinguishing patients that can be managed
conservatively from those who need surgery, thus improving the
long-term outcome of patients.
• Radiologic interventions
-Renal artery angiography and embolisation/stenting.
-External drainage procedures (eg-Urinomas)
9. Classification of renal trauma-AAST
• Grade 1
Subcapsular hematoma, parenchymal contusion without laceration, or both
• Grade 2
Perirenal hematoma confined to Gerota fascia
Renal parenchymal laceration of ≤ 1-cm depth without urinary extravasation
• Grade 3
Renal parenchymal laceration of > 1-cm depth without collecting system rupture
or urinary extravasation
Any injury in the presence of a kidney vascular injury or active bleeding contained
within the Gerota fascia
• Grade 4
Parenchymal laceration extending into urinary collecting system with urinary
extravasation
Renal pelvis laceration, complete ureteropelvic disruption, or both
Active bleeding beyond the Gerota fascia into the retroperitoneum or peritoneum
Segmental renal vein or artery injury or segmental or complete kidney infarction(s)
caused by vessel thrombosis without active bleeding
• Grade 5
Shattered kidney with loss of identifiable parenchymal renal anatomy
Devascularized kidney with active bleeding
Main renal artery or vein laceration or avulsion of hilum
10.
11. Updated Content in 2018 AAST Kidney Injury
Scale
Grade I Clinical descriptors for renal contusions have been removed
Contusions are recognized as being visible on MDCT
The term “nonexpanding” has been removed
Grade II The term “nonexpanding” has been removed
The term “renal retroperitoneum” has been replaced by “hematoma
confined within Gerota’s fascia”
The size of the laceration is now inclusive of 1 cm
Grade III Incorporates vascular injury (pseudoaneurysms and
arteriovenous fistulas) and active bleeding but previously were not
12. Grade IV: Incorporates renal pelvis laceration and complete
ureteropelvic disruption
Active bleeding is explicitly categorized
Injuries to the main renal vessels, excluding thrombosis, are now grade V
injuries (previously grade IV on 1989 AAST renal injury scale)
Segmental vascular compromise and infarction have been included but
previously were not described
Infarction as a sequela of vascular thrombosis has been added
Grade V: Active bleeding included
In addition to avulsion at the renal hilum, the main renal artery or vein
injury descriptor now also includes “laceration” All main renal vascular
injuries, excluding thrombosis, are reserved for grade V injuries
13. Federle Classification
• Category I- MINOR
-Contusion
-Cortical laceration not extending into a
calyx.
• Category II- MAJOR
-Cortical laceration extending into the collecting
system(renal fracture)
• Category III- CATASTROPHIC
-Renal pedicle injuries
-Shattered kidney
• Category IV
-PUJ Injuries.
15. IVU
• Historical interest, largely replaced by cross sectional imaging.
• Quality of IVU in the setting of trauma is likely to be poor;
hypotensive patient - minimal or no secretion from both kidneys.
• Single shot IVU(full length film 15 mins after contrast
injection):in hemodynamically unstable patients destined for ER
laparotomy.
• Provides information regarding:
-presence of functioning contralateral kidney.
-some gross information about the injured kidney.
16. IVU (..contd)
• Absence of unilateral excretion: major vascular injury (usually RA
avulsion)
• Soft tissue swelling with loss of psoas outline: retroperitoneal,
perinephric and subcapsular hematomas.
• Disruption of PCS: extravasation of opacified urine (70% sensitivity
for urine leak)
• Intra-operative IVU in severely injured patients.
17. USG
• Advantages:
easily available, non invasive, high negative predictive
value(96-98%)
• Disadvantages:
-poor resolution (compared to CT)
-does not provide information about renal unction.
-significant trauma may be missed(upto 80%of
parenchymal lesions may be overlooked)
18. Findings in USG
• Acute parenchymal, subcapsular and perinephric hematomas
- echo poor areas.
• More heterogenous and echogenic with time.
• Disruption of renal parenchyma with capsular tears and
urinomas.
• Doppler-pedicle injuries.
19. Ultrasound gray-scale image shows normal right kidney.
Doppler study shows absent colour uptake in intrarenal arteries
s/o grade V injury.
20. CT of the same patient-non enhancement of right kidney(grade V)
with small perinephric and intraperitoneal hemorrhage.
21. Grade IV renal injury. Sonogram in an 8-year-old child with
posttraumatic renal infarction shows both kidneys with an
avascular area in the lower half of the affected kidney
22. Grade IV renal injury. Sonogram of the same patient shows
progressive shrinkage of the lower half as the kidney goes
ischemic autopartial nephrectomy
23. CT Scan
• Modality of choice, most accurate technique.
• Allows assessment of entire abdomen, including liver and spleen.
• Arterivenous phase
• Delayed scan@ 10-20 min
? omit if normal kidneys with no perinephric, retroperitoneal or
pelvic fluid.
24. • Technique:
- the abdomen and pelvis should be scanned from the
diaphragmatic dome to pubic symphysis with contrast.
-Protocol: >commence scanning 30 sec after the start of an
injection of 50-100ml of 300 strength contrast at 2-3 ml/sec,
collimation 7 mm, pitch 1.3.
>addition of 400-600 ml of oral contrast (4% diatriazoate)
immediately before scan helps in delineating associated
bowel injuries (stomach,duodenum and proximal jejunum).
25. • To perform a complete evaluation, the entire scan must be
scrutinized with 3 different window/level settings: soft tissue,
lung, and bone. The entire systemic review has been called
the "every-organ-on-every-slice" approach (West, 2000).
26. Grade I Injuries
• Contusions and subcapsular hematoma are key terms used in the
identification of grade I renal injury
• Contusions appear on portal venous phase CT images as globular,
ovoid, or round poorly demarcated areas of relatively poor
enhancement
• Subcapsular hematomas are confined by the renal capsule. These
are seen as non-enhancing crescentic or lentiform shaped fluid
collections that may exert some mass effect on the underlying
renal parenchyma
27. Grade I renal injury, contusion-shows ill-defined area of
hypoenhancement in the medial right kidney.
28. Grade I renal injury, subcapsular hematoma-Image shows crescentic high-
density fluid collection around the left kidney with well-defined outer margin
30. Grade II Injuries
• Perinephric hematomas and renal parenchymal lacerations are
key terms used in the identification of grade II renal injury
• Hematoma contained within the Gerota fascia has been
postulated to have a tamponade effect on renal bleeding,
resulting in perinephric clot formation
• In grade II injuries, lacerations are superficial (≤ 1 cm), and
there is no urine leak
31. Grade II renal trauma-an ill-defined fluid collection in the left perinephric
space and subcapsular hematoma with deformity of the renal parenchyma.
32. Grade II renal injury-superficial (less than 1 cm deep) renal
parenchymal defect with a large perinephric hematoma
33. Axial IV contrast-enhanced abdominal CT image shows
laceration (arrowhead) 8.4 mm in size (line A) at anterior
aspect of mid pole of left kidney. Small lacerations or those that
have oblique course can be challenging to visualize on single
plane. Adjacent perirenal hematoma (arrow) should prompt
closer examination for subtle lacerations.
34. Grade III Injuries
• Grade III descriptors are deeper lacerations (> 1 cm) that do not
result in urine leak
• any injury occurring in the presence of a vascular injury is
considered to denote grade III injury. Vascular injuries include
pseudoaneurysm or arteriovenous fistula, These have been described
as a focal collection of vascular contrast enhancement that shows
decreasing attenuation with delayed imaging
• Active bleeding : It is defined by vascular contrast enhancement
(focal or diffuse) that increases in size and attenuation in the delayed
phase. If this is present, it must be contained within the Gerota fascia
35. Grade III renal laceration, IVU-diminished left nephrogram and
no urinary contrast extravasation, CT-renal parenchymal defect
with extension greater than 1 cm deep to near the renal pelvis
37. CECT image obtained in venous phase (B) shows laceration larger than 1 cm
(size, 12.4 mm ) to lower pole of right kidney (arrow) with adjacent high-
attenuation perirenal fluid.
CECT image (C) obtained in delayed phase (10 minutes after administration of
contrast medium) does not show urine leak, confirming injury is grade III.
38. A 45-Year-Old Man Imaged Following a Stab Injury to His Left Flank.
(A) Axial unenhanced multidetector computed tomography image shows
a large left perinephric haematoma (asterisk). (B) Axial portal venous
phase imaging demonstrates a high-density focus representing a
pseudoaneurysm (arrow), which remains isodense to the aorta on
delayed images (C).
39. Grade IV Injuries
• Include injuries to the renal parenchyma and collecting system as
well as vascular injuries
• Lacerations extending deep to involve the collecting system with
urinary extravasation are included,
• Delayed imaging usually shows urine leaking into the perirenal
space, as evidenced by the attenuation of the uncontained contrast
medium matching the high attenuation of urine within the collecting
system
40. • Segmental renal vascular injury: These injuries can manifest as
segmental infarctions of the renal parenchyma that are seen on
MDCT as a wedge-shaped area of non-enhancement, with the wider
base at the renal capsule and the apex pointing toward the renal
hilum, segmental or complete renal infarction due to vessel
thrombosis in the absence of active bleeding
• active bleeding extending beyond the Gerota fascia: Active bleeding
into the kidney or surrounding tissue appears as patchy ‘flame-
shaped’ or linear dense contrast material surrounded by less dense
hematoma on arterial-phase images, The attenuation of the
extravasated contrast material is similar to that of the opacified aorta
41. A Axial CECT shows low-attenuation perirenal fluid (long arrow) medial to left kidney,
indicating possibility of injury to collecting system. Short arrow shows mildly displaced
fracture of left transverse process of L3
B, Axial CECT delayed phase at same level as image in A, obtained after 10 minutes in
bone window confirms presence of low-attenuation perineal fluid (long arrow) caused
by urine extravasation partially outlining renal pelvis (short arrow).
C, Axial CECT delayed phase abdominal CT image acquired at level inferior to left
lower renal pole 10 minutes after administration of contrast medium shows contrast
medium within mid left ureter (long arrow), which indicates some continuity of
collecting system on left side, despite urine leak(short arrow)
42. A, Axial CECT shows large left perirenal hematoma, confined by Gerota fascia with
active bleeding (arrow) and non enhancing segments (arrowheads) within medial left
kidney, indicating devascularization secondary to segmental vascular injury.
B, Axial CECT shows hyperenhancing focus (arrow) within large lower pole
laceration. On delayed phase images (not shown), this focus showed decreased
attenuation and size, confirming pseudoaneurysm. In isolation, pseudoaneurysm can be
found in grade III injury. However, according to 2018 AAST kidney injury scale, when
more than one grade of injury is present in same kidney, overall grade assigned
conforms to higher grade of injury.
43. (A) Arterial-phase multidetector computed tomography image demonstrates a
large left perinephric hemorrhage with an oval focus of high density adjacent to
the posterior aspect of the mid-kidney (arrow). (B) Portal venous phase image
at the level of the lower pole shows the focus has remained dense and
increased in size (arrows), diagnostic of active bleeding
44. Grade IV renal injury segmental infarction. Shows a segmental
area of nonenhancement in the upper medial left kidney without
associated renal laceration.
45. Grade V Injuries
• Shattered kidney, avulsion or laceration of the main renal artery, main
renal vein, or both, and devascularized kidney with active bleeding are key
terms used in the identification of grade V renal injury
• Shattered kidney: the loss of identifiable renal parenchymal anatomy, The
renal parenchyma is separated into multiple fragments, some of which may
be devascularized, this is the severest form of parenchymal laceration and
it usually occurs with urine leak and active bleeding
• Hilar vascular injuries are not common
• Complete arterial tears result in retroperitoneal hematomas with possible
active bleeding
47. A B
30-year-old pedestrian who was struck by car
A, Axial IV contrast-enhanced portal venous phase abdominal CT image shows right perirenal
hematoma with hemorrhage mostly located medial to right kidney and surrounding renal hilar
structures. Saccular outpouching from anterior wall of distal renal vein (arrow) indicates vascular
injury.
B, Axial IV contrast-enhanced delayed phase abdominal CT image shows striated nephrogram of
right kidney (linear areas of hyperenhancement in renal cortex), which may result from shearing
stress to parenchyma. No active extravasation was seen between two phases, and there was no
collecting system injury.
48. Grade V renal injury, devascularization. CECT shows dissection of
the origin of the left renal artery, with no perfusion of the left kidney.
Also, a hematoma can be noted along the anterior renal fascia.
49. MRI
• MRI provides excellent detail of the renal anatomy but offers
no clear advantage over CT, and is less able to detect
extravasation.
• A rare indication for MRI in the renal trauma setting may be
severe contrast allergy
50. Treatment and prognosis
• grade I - conservative management
• grade II - conservative management under close observation
• grade III - conservative management under close observation.
May be managed surgically if undergoing laparotomy for other
abdominal injuries
• grade IV - surgical management, especially if undergoing
laparotomy for other abdominal injuries
• grade V - surgical management
52. Ureteric trauma
• <1% of urinary tract trauma
• Mechanism of injury:
External:
Penetrating injuries
Deceleration injuries:
-PUJ avulsion,
-less often upper 1/3rd of ureter
-more frequent in children(sufficient flexibility
to produce hyperflexion injuries)
Iatrogenic: gynecologic surgery for malignancy.
• Hematuria may be absent in one third of cases
53. AAST Ureteral Injury Scale
Grade Type of Injury Description of Injury
I Hematoma Contusion of hematoma without
devascularization
II Laceration <50% transection
III Laceration >50% transection
IV Laceration Complete transection with <2%
devascularization
V Laceration complete transection with
>2% devascularization
54. Imaging Findings:
• IVU:
-mild to moderate fullness of the PCS and extravasation at the site of tear.
- complete tear-ureter fails to opacify below the tear.
-fistulations to other structures.
• Retrograde pyelogram:
-findings as above.
-limited use in acute setting.
• CT: Delayed excretory phase images are usually required to make the
diagnosis
Contrast extravasation
Formation of urinoma
Occurance of Ureteric discontinuity
55. Iatrogenic ureteric injury. Excretory phase coronal computed
tomography image shows contrast extravasation from the proximal
ureter into surrounding retroperitoneal urinoma (arrow).
57. • Blunt trauma: most common
- in patients with multi injury trauma
- predisposed by full bladder at the time of trauma.
- pelvic fractures(especially anterior ring) commonly associated
-7 % symphysis pubis diastasis associatr with bladder trauma.
• Spontaneous:
• pre-existing bladder wall abnormalities &/or excessive
straining
-bladder tumor, cystitis, perivesical inflammation, BOO,
neurogenic bladder, previous radiotherapy.
• Iatrogenic trauma:
Surgery particularly caesarean section and transurethral bladder
resection( usually for tumor)
58. Classification
1 Contusion (incomplete or partial tear of the bladder
mucosa, imaging findings usually normal)
2 Intraperitoneal rupture(contrast material seen
around bowel loops and in the major peritoneal
spaces)
3 Interstitial bladder injury(rare, contrast material
dissects into bladder wall but not outside the
bladder)
4 Extraperitoneal rupture(contrast seen within the perivesical
space and a variable number of adjacent extraperitoneal
spaces, depending upon the severity of injury)
5 Combined intraperitoneal and extraperitoneal rupture.
60. Conventional Cystography
• Advantages:
-nearly 100% sensitive for detecting rupture, provided that
adequate distention is accomplished and that post voiding images
are obtained.
• Disadvantages:
-time consuming,
-require extra radiography in addition to necessary trauma
evaluation.
-not useful in evaluating trauma to other viscera.
61. CT Cystography
• Technique:
- performed with ~350- 400 mL of contrast material
administered in a retrograde fashion before the study.
Washout study:
• Advantages of CT Cystography
-less time consuming.
-concomitant injury to other viscera(most importantly the
kidneys)
• The absence of free fluid in the abdomen during the CT is a
strong negative predictor of bladder injury.
62. Imaging findings
• Extraperitoneal rupture:
-commonest bladder injury(90% of cases)
-associated with anterior pelvic ring fracture in 90% of cases.
-extravasation of contrast into the perivesical space-
- in florid extravasation, contrast may extend
anterosuperiorly along the anterior pelvic and
abdominal wall upto umbilicus, or posteriorly around
the rectum in presacral space.
-associated tear of urogenital diaphragm allowing the
contrast to appear within the perinerum, thigh and
scrotum.
• The extravasated contrast stays close to the bladder and has a
sharp irregular margins.
64. (CT) cystogram demonstrating a complex extraperitoneal
bladder rupture with contrast material extending through the
fascial planes of the pelvis.
65. • Intraperitoneal rupture
-contrast extravasates into the peritoneal cavity and has a
more cloudy nebulous appearance.
-usually tear is along the dome of bladder which is the
weakest part.
-associated pelvic fractures seen in 75%
68. Urethral trauma
• Almost entirely restricted to males
unless there is major pelvic trauma
in females.
• Should be suspected
-pelvic trauma associated with
hematuria or retention
-especially blood at the
urethral meatus.
69. Male urethral injuries
Type Membranous
urethra
Bulbar
Urethra
Contrast
Extravasation
Perineum Retropubi
c space
I Contusion or
partial tear
Normal or
stretched
No No
II Rupture above
UGD
Normal or
stretched
No Yes
III Rupture below
UGD
Ruptured Yes No
70. Classification of Urethral Injuries
Grade Colapinto & McCallum
I Posterior urethra
stretched but intact
II Posterior urethral tear
above intact urogenital
diaphragm (UGD)
III Posterior urethral tear
with extravasation
through torn UGD
IV —
IVa —
V —
Goldman & Sandler
Posterior urethra stretched but
intact
Partial or complete posterior
urethral tear above intact UGD
Partial or complete tear of
combined anterior and posterior
urethra with torn UGD
Bladder neck injury with
extension to the urethra
Injury to bladder base with
extravasation simulating type IV
(pseudo-grade IV)
Isolated anterior urethral injury
71. Retrograde urethrogram reveals a type I urethral injury with
minimal stretching and slight luminal irregularity of the
posterior urethra. No extravasation of contrast material is
present
72. Retrograde urethrogram - type II urethral disruption.
Extravasation of contrast material (solid arrow) from the
posterior urethra is seen superior to an intact urogenital
diaphragm (dashed arrow).
73. Retrograde urethrogram - type III urethral injury.
Extravasation is located in both the extraperitoneal pelvis and
in the perineum (above and below the urogenital diaphragm).
74. Anterior urethral trauma
• Mechanisms:
-iatrogenic (attempted catheterisation,instrumentation)
-blunt perineal trauma(straddle injury):bulbar urethra and
corpus spongiosum are compressed against the inferior
aspect of anterior pelvic ring.
75. Straddle injury. Retrograde urethrogram shows a type 5
urethral injury with extravasation of contrast material from the
distal bulbous urethra.
78. Penile fracture
• Fracture of the penis occurs exclusively with an erection, with
aggressive vaginal intercourse being the most common cause
• It is related to excessive bending of the erect penis and thrusting
against the pubic symphysis
• The patient usually reports a cracking sound, immediate pain,
and rapid detumescence
79. 44-year-old man who heard popping sound during sexual intercourse.
(a)Transverse sonogram of penis shows defect in tunica albuginea of
left corpus cavernosum (arrows) and large surrounding hematoma.
(b)Photograph of penis shows ecchymosis, giving “eggplant”
appearance to penis
a b
81. • Trauma often may result in hematoma, hydrocele, hematocele,
testicular fracture, or testicular rupture
• Intratesticular hematomas are common after trauma.
• The ultrasound appearance depends on the time between
occurrence of trauma and ultrasound evaluation.
• Acute hematomas are typically isoechoic to the normal
testicular parenchyma and can be difficult to identify.
82. Intratesticular hematoma. (a) Sagittal gray-scale US image shows an ill-
defined hypoechoic area (arrows) that represents a hematoma in the
posterior part of the left testis. (b) Sagittal color Doppler image shows
flow in the testis, except in the area of hematoma, where there is a
testicular fracture
83. Hydroceles in two patients. (a) Transverse US image of the left scrotum
shows a large hydrocele that has displaced the testis (T) anteriorly. (b)
Sagittal image shows a very large right-sided hydrocele that contains
fine internal septa, with the right testis (area demarcated by cursors)
displaced posteriorly.
84. Hematocele due to testicular rupture immediately after blunt scrotal
trauma. Transverse US images (b slightly superior to a) show uniformly
echogenic fluid surrounding the testis (T), a finding indicative of blood
in a hematocele. EPI-epididymis.
85. • Testicular rupture implies tearing of the tunica albuginea with
extrusion of testicular parenchyma into the scrotal sac.
• The margins of the testis are poorly defined and the
echogenicity of the testis is heterogeneous.
• The use of colour Doppler is essential as rupture of the tunica
albuginea will almost always be associated with a loss of
vascularity to a portion of or the entire testis.
86. Testicular fracture. (a) Transverse US image of the testis shows a
hypoechoic irregular linear area (arrow) indicative of a fracture. (b)
Transverse color Doppler image depicts normal flow throughout the
testis, except in the area of the fracture (arrow).
87. Testicular rupture. (a) Sagittal gray-scale US image demonstrates
extrusion of the testicular contents (arrows) through the tunica
albuginea. (b) Color Doppler image shows multiple hypoechoic foci
with no flow (arrowheads) in the periphery of the testis, findings
indicative of hematomas or infarcts.
88. • Trauma to the testis can also result in dislocation or torsion.
• Dislocation most commonly results from impact of the
scrotum against the fuel tank in motorcycle accidents.
• Testicular dislocation, typically into the inguinal canal, may
be detected by CT or ultrasound.
• Testicular torsion is preceded by trauma in 5–8% of cases.
89. References
• Textbook of radiology and imaging David Sutton 7th edition
• Grainger and Allison’s Diagnostic Radiology 7th edition
• Coming Together: A Review of the American Association for the
Surgery of Trauma’s Updated Kidney Injury Scale to Facilitate
Multidisciplinary Management-AJR Article
• US of Acute Scrotal Trauma: Optimal Technique, Imaging Findings,
and Management - RSNAArticle
• Radiopedia
• Images from internet
Editor's Notes
Advance one grade for multiple injuries to the same organ.More than one grade of kidney injury may be present, and overall classification should be made on the basis of the higher grade of injury. Advance one grade higher for
bilateral injuries up to grade III.Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast enhancement that decreases in
attenuation with delayed imaging.Active bleeding is defined as vascular contrast, focal or diffuse, that increases in size and attenuation in delayed phase.
Updated Content in 2018 AAST Kidney Injury Scale
I Clinical descriptors for renal contusions have been removed
Contusions are recognized as being visible on MDCT
The term “nonexpanding” has been removed
II The term “nonexpanding” has been removed
The term “renal retroperitoneum” has been replaced by “hematoma confined within Gerota’s fascia”
The size of the laceration is now inclusive of 1 cm
III Incorporates vascular injury (pseudoaneurysms and arteriovenous fistulas) and active bleeding but previously were not described
IV Incorporates renal pelvis laceration and complete ureteropelvic disruption
Active bleeding is explicitly categorizedInjuries to the main renal vessels, excluding thrombosis, are now grade V injuries (previously grade IV on 1989 AAST renal injury scale) Segmental vascular compromise and infarction have been included but previously were not describedInfarction as a sequela of vascular thrombosis has been added
V Active bleeding includedIn addition to avulsion at the renal hilum, the main renal artery or vein injury descriptor now also includes “laceration” All main renal vascular injuries, excluding thrombosis, are reserved for grade V injuries
31-year-old woman who fell against concrete slab and sustained grade II injury according to both 1989 American Association for the Surgery of Trauma (AAST) renal injury scale and 2018 AAST kidney injury scale. Axial IV contrast-enhanced abdominal CT image shows laceration (arrowhead) 8.4 mm in size (line A) at anterior aspect of mid pole of left kidney. Small lacerations or those that have oblique course can be challenging to visualize on single plane. Adjacent perirenal hematoma (arrow) should prompt closer examination for subtle lacerations.
Arteriovenous fistulas have been previously described as identifiable on the basis of early enhancement of the renal vein during the arterial phase and increased caliber of the renal vein, whereas pseudoaneurysms have been described as well-marginated, ovoid, or round collections that follow the arterial blood pool and appear as washout on delayed phase images
Pseudoaneurysms will appear as a rounded or oval area of high density on arterial-phase imaging that becomes isodense on portal venous images
B and C, 31-year-old man involved in motor vehicle accident. Axial IV contrast-enhanced abdominal CT image obtained in venous phase (B) shows laceration larger than 1 cm (size, 12.4 mm [line A]) to lower pole of right kidney (arrow) with adjacent high-attenuation perirenal fluid. Without benefit of delayed phase imaging, perirenal fluid could be either hemorrhage or mixture of hemorrhage and urine. Axial IV contrast-enhanced abdominal CT image (C) obtained in delayed phase (10 minutes after administration of contrast medium) does not show urine leak, confirming injury is grade III.
47-year-old male pedestrian who was struck by car and sustained grade IV injury according to 2018 American Association for the Surgery of Trauma (AAST) kidney injury scale. Injury does not fit any grade descriptors in 1989 AAST renal injury scale.A, Axial IV contrast-enhanced abdominal CT image obtained at level of left renal mid pole shows low-attenuation perirenal fluid (long arrow) medial to left kidney, indicating possibility of injury to collecting system. Short arrow shows mildly displaced fracture of left transverse process of L3.
B, Axial IV contrast-enhanced delayed phase abdominal CT image acquired at same level as image in A, obtained 10 minutes after administration of contrast medium, and seen in bone window confirms presence of low-attenuation perineal fluid (long arrow) caused by urine extravasation partially outlining renal pelvis (short arrow).C, Axial IV contrast-enhanced delayed phase abdominal CT image acquired at level inferior to left lower renal pole 10 minutes after administration of contrast medium shows contrast medium within mid left ureter (long arrow), which indicates some continuity of collecting system on left side, despite urine leak, which can be seen in this image lateral to ureter and anterior to left psoas muscle (short arrow). Extensive subcutaneous bruising and hematoma along soft tissues of left flank are also noted. Retrograde pyelogram was obtained 1 day later during orthopedic fixation surgery. Contrast extravasation from proximal collecting system was again seen during this procedure, similar to that seen on initial CT (not shown).Six-French double-J ureteric stent was placed (nonsurgical management).
22-year-old man who was involved in motor vehicle accident and sustained grade IV injury according to 2018 American Association for the Surgery of Trauma (AAST) kidney injury scale. Injury did not correspond to any 1989 AAST renal injury scale grades.A, Axial IV contrast-enhanced abdominal CT image shows large left perirenal hematoma, confined by Gerota fascia with active bleeding (arrow) and nonenhancing segments (arrowheads) within medial left kidney, indicating devascularization secondary to segmental vascular injury. Left renal vein is normal, as is left renal artery (not shown).
B, Axial IV contrast-enhanced abdominal CT image obtained at lower pole of left kidney shows hyperenhancing focus (arrow) within large lower pole laceration. On delayed phase images (not shown), this focus showed decreased attenuation and size, confirming pseudoaneurysm. In isolation, pseudoaneurysm can be found in grade III injury. However, according to 2018 AAST kidney injury scale, when more than one grade of injury is present in same kidney, overall grade assigned conforms to higher grade of injury.
This is in contradistinction to grade IV in- juries in which devascularization is caused by vascular thrombosis and there is no active bleeding
Ureteral injury from blunt trauma is uncommon, and occurs in less than 1% of all genitourinary trauma. The low incidence of ureteral injury is likely owing to the fact that the ureters are deep in the retroperitoneum, and relatively well-protected by surrounding fat and soft tissue.
Iatrogenic ureteral injuries can occur during gynecologic, obstetric, urologic, colorectal, general, or vascular surgery; gynecologic surgery accounts for more than half of all iatrogenic injuries.
AAST trauma grading has not been verified as accurate on imaging studies
The abdominal molar tooth sign refers to the appearance of contrast media which has spilled out of the urinary bladder on CT cystography after extraperitoneal bladder rupture.
Contrast flows out of the ruptured bladder, occupying the preperitoneal cavum Retzii and surrounds the bladder in the shape of a molar tooth
Found in 10% of significant pelvic fractures.
Posterior urethral injuries are usually diagnosed by retrograde ure- thrography but are occasionally seen on pelvic CT. Posterior displacement of the bladder and urethra in blunt trauma creates a characteristic ‘S-bend’ appearance of the urethra on urethrography, if the lumen remains intact. Complete transection of the urethra results in extravasa- tion of the contrast material into the periurethral soft tissues, while a partial laceration will also demonstrate some filling of the proximal ureter and bladder
The most common injury is a Goldman type III, which involves a laceration of both the anterior and posterior urethra.
Ultrasonography (US) is the first-line imaging modality to help guide therapy for scrotal trauma, except in degloving injury, which results in scrotal skin avulsion.
Blunt injury (eg, from an athletic accident or motor vehicle collision) is the most common cause of scrotal trauma, followed by penetrating injury from gunshot or other assault.
Scrotal trauma accounts for less than 1% of all trauma-related injuries, because of the anatomic location and mobility of the scrotum. The peak occurrence of scrotal trauma is in the age range of 10 –30 years .
The right testis is injured more often than the left one because of its greater propensity to be trapped against the pubis or inner thigh.