Renal Trauma Notes

Renal Trauma

Definition of Trauma

  • Trauma: Physical injury or a wound to living tissue caused by an extrinsic agent.

  • Types of trauma:

    • Intentional injury

    • Unintentional injury (accident)

Types of Renal Trauma

  • Blunt Injury (80-90%)

    • Caused by impact from an object without an open wound.

    • Rapid deceleration (e.g., MVA, fall from heights).

    • Direct blow to the flank (e.g., pedestrian struck, sports injury).

    • Normally minor and self-limiting.

  • Penetrating Injury

    • Results from gunshot & stabling.

    • More severe and most likely require surgical management.

Etiology

  • Blunt.

  • Penetrating.

  • Iatrogenic (e.g., endourologic procedures, EWSL, renal biopsy, percutaneous renal procedures).

  • Intraoperative (e.g., diagnostic peritoneal lavage).

  • Others: spontaneous renal laceration caused by childbirth.

Trauma Grade (AAST)

  • The American Association for Surgery of Trauma (AAST) Renal Injury Scale grades renal trauma from I to V, with increasing severity.

  • Grade I

    • Type: Contusion, Hematoma

    • Description:

      • Microscopic or gross hematuria.

      • Urological studies normal.

      • Subcapsular, non-expanding without parenchymal laceration.

      • Non-expanding peri-renal hematoma confined to renal retroperitoneum.

  • Grade II

    • Type: Hematoma, Laceration

    • Description:

      • < 1.0cm parenchymal depth of renal cortex with no urinary extravasation.

  • Grade III

    • Type: Laceration

    • Description:

      • > 1.0cm parenchymal depth of renal cortex w/out collecting system rupture or urinary extravasation.

  • Grade IV

    • Type: Laceration, Vascular

    • Description:

      • Parenchymal laceration extending through renal cortex, medulla & collecting system.

      • Main renal artery or vein injury with contained hemorrhage.

  • Grade V

    • Type: Vascular, Laceration

    • Description:

      • Completely shattered kidney.

      • Avulsion of renal hilum that devascularizes the kidney.

Clinical Manifestations

  • Massive bleeding (even with small laceration).

  • Hematuria (Bright red color).

  • Pain at injury area.

  • Renal colic (due to blood clots or fragment obstruct the collecting system).

  • Mass or swelling in flank/abdomen.

  • Visible injury (hematoma, wounds on flank/lateral abdomen).

  • Hypovolemia.

  • Low-grade fever.

Diagnostic Tests

  • Hematocrit & Hb: Low indicate bleeding.

  • BUSE & Renal function test: High indicates impending kidney failure.

  • Urinalysis: Presence of blood may indicate injury involves renal arteries.

  • Ultrasound pelvic

  • CT pelvic: For complicated cases.

Complications

  • 3-33%.

  • Urinary extravasation (most common): Urine leaks out of the kidney.

  • Infection (perinephric abscesses).

  • Delayed hemorrhage.

  • Hypertension.

  • Renal insufficiency.

Complications After Repair

  • Acute

    • Clot retention.

    • Local infection.

    • Sepsis.

  • Late (5%)

    • Urethral stricture.

    • Frequency urination.

    • Dysuria.

    • Urethrocutaneous fistula.

    • Failure to heal.

Emergency Nursing Management

  • Assessment:

    • Primary and secondary survey

    • Stable patient - blunt trauma, Grade I, II & III renal trauma

    • Unstable patient - active bleeding, Grade IV & V renal trauma

  • Control hemorrhage, pain, and infection.

  • Preserve and restore renal function.

  • Maintain urinary drainage. Insert CBD.

  • Mark the hematoma/swelling border to monitor further hemorrhage.

  • Set IV line with larger size cannula.

  • Obtain blood for FBC, BUSE, renal profile, blood group, and crossmatch.

  • Collect urine for urinalysis.

  • Monitor for oliguria & signs of hemorrhagic shock.

  • Prepare patient for ultrasound/CT scan.

Management for Stable Patient

  • No active intervention.

  • CRIB until gross hematuria resolved without bladder irrigation.

  • Close monitoring.

  • Assess hematoma/swelling BD.

  • Monitor I/O and hematuria.

  • Avoid anticoagulants.

  • Antimicrobial medication to prevent infection from perirenal hematoma or urinoma.

Management for Unstable Patient

  • Aggressive fluid resuscitation.

  • Surgical if:

    • Failure to respond to blood transfusion

    • Massive hematuria

    • Expanding loin mass

    • Penetrating trauma

  • Embolization/angioembolization.

  • Laparotomy renal exploration.

  • Partial/total nephrectomy.

  • Ureteric stenting.

Post-Op Management

  • CRIB until gross hematuria resolved.

  • Assess the incision site, dressing, draining for bleeding.

  • Continuously monitor vital signs and blood investigation.

  • Monitor I/O and hematuria.

  • Assess pain score.

  • Monitor for signs and symptoms of infection.

  • Administer antibiotics.

  • Educate to restrict physical activities for 1/12 (one month).

  • Advice to follow up to assess renal function.

  • Acute pain related to injuries and trauma.

  • Fear and anxiety related to the outcome of trauma.

  • Risk of hypovolemia related to severe blood loss.