Renal truma Medical Presentation

Renal Truma PowerPoint Presentation

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Published on : Aug 23, 2019 | Views : 2336 | Downloads : 10

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Background The kidney is well protected by heavy lumbar muscles, vertebral bodies, ribs, and the viscera anteriorly. Renal trauma occurs in approximately 1-5% of all traumas. Renal injuries are the most common injuries of the urinary system. Blunt trauma directly to the abdomen, flank, or back is the most common mechanism, accounting for 80-85% of all renal injuries. Kidneys with existing pathologic conditions such as hydronephrosis or malignant tumors are more readily ruptured from mild trauma.
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Mechanism of injury
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Classification of renal injuries
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Classification of renal injury Minor renal trauma (85% of cases)- (grade 1-3) Renal contusion or bruising of the parenchyma is the most common lesion. Subcapsular hematoma in association with contusion is also noted. Superficial cortical lacerations are also considered minor trauma. These injuries rarely require surgical exploration. Major renal trauma (15% of cases)-(grade 4&5) Deep corticomedullary lacerations may extend into the collecting system, resulting in extravasation of urine into the perirenal space. Large retroperitoneal and perinephric hematomas often accompany these deep lacerations. Multiple lacerations may cause complete destruction of the kidney. Laceration of the renal pelvis without parenchymal laceration from blunt trauma is rare. Vascular injury (about 1% of all blunt trauma cases)-(grade 4&5) Vascular injury of the renal pedicle is rare but may occur, usually from blunt trauma. There may be total avulsion of the artery and vein or partial avulsion of the segmental branches of these vessels. Vascular injuries are difficult to diagnose and result in total destruction of the kidney unless the diagnosis is made promptly.
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Symptoms
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Signs The following findings on physical examination may indicate possible renal involvement :
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Bruising after blunt renal injury
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Management Initial emergency assessment Securing of the airway Controlling any of the external bleeding Resuscitation of shock Physical examination is carried out during stabilization
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Laboratory Investigations Urine from a patient with suspected renal injury should be inspected grossly and then by dipstick analysis for hematuria. Blood sample should be sent for blood grouping and serum saved for cross matching. Serial hematocrit measurement indicates blood loss ( renal or associated injuries ? ) Creatinine measurement reflects renal function prior to the injury.
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Indications of radiographic evaluation Blunt trauma patients with hematuria (macroscopic or microscopic) with hypotension (systolic blood pressure < 90 mmHg ). 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.
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Radiological investigations
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Grade I injury (subcapsular hematoma)
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Grade II injury
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Grade IV injury
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Grade III injury
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Grade 5 injury
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Treatment Non-operative management is the treatment of choice for the majority of renal injuries Conservative watchful treatment of closed renal trauma is usually successful. 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%
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Conservative treatment Stable patients following grade 1-4 blunt renal trauma , should be managed conservatively. Stable patients , following grade 1-3 stab and low velocity-gunshot wounds after complete staging , should be selected for expectant management
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We try to avoid surgical exploration because:
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Conservative management
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Surgical treatment Indications for surgical management include :
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Surgical treatment Renal reconstruction should be attempted in cases where the primary goal of controlling hemorrhage is achieved and sufficient amount of renal parenchyma is viable. If the kidney is completely destructed or there is uncontrollable life threatening bleeding then nephrectomy provided the other kidney. When a solitary kidney is sufﬁciently damaged to need exploration, it must be repaired. Failing this, the wound is packed ﬁrmly with gauze to stop the bleeding in the hope that some renal function may be retained when the ruptured kidney heals.
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Early Complications
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Delayed complications
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Trauma to the ureters is relatively rare because they are protected from injury by their small size, mobility, and the adjacent vertebrae, bony pelvis, and muscles. Ueteral trauma accounts for 1-2.5% of urinary tract trauma.
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Etiology
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Injury to one or both ureters during pelvic surgery
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Types of injury Ligation with suture. Crushing Transection ( complete or partial) Angulation (kinging) Diathermy related injuries. Resection. Ischemia from devascularization. Injury specially occurs if there is bleeding or in distorted anatomy.
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Diagnosis of ureteral injury ‘ the venial sin is the injury to the ureter; The mortal sin is failure of recognition’ Unfortunately only 1/3 of ureteral injuries are diagnosed intraoperatively. By: Directly visualizing. Extravasation of urine. Ureter become dilated (if distal obstruction) Dye test (methylene blue or indigo carmine given I.V)
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Injury not diagnosed at the time of surgery; there are 3 possibilities:
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Symptoms (postoperative period)
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Signs
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Investigations Laboratory: 1.Microscopic hematuria. 2.leukocytosis. 3. Elevated renal function. Diagnosis is by Excretory Urography or contrast enhanced CT scan (with delayed films). Ultrasound shows hydronephrosis or Urinoma development.
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Treatment Depends on the timing of discovering the injury and general condition of patient. If the injury is diagnosed intraoperatively or in the early postoperative period and the patient condition is stable immediate repair. If the patient condition is unstable then temporary urine diversion by nephrostomy followed by repair.
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Ureter repair options Upper ureteric injury: either 1. Primary anastomosis by ureteroureterostomy. 2. Ileal interposition. 3. Auto transplantation. Mid – ureteric injury: 1. Primary anastomosis by ureteroureterostomy. 2.trans uretero-ureterostomy. Lower ureteric injury : Reimplantation of ureter. ( Psous Hitch or Boari flap)
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Is a common urological injury The bony pelvis protects the bladder very well; when the pelvis is fractured by trauma, fragments of the fracture may penetrate the bladder. 15% of pelvic fractures are associated with bladder injury. Distended bladder at the time of accident is more liable for injury.
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Types Extraperitoneal rupture (80%). 90% of cases are associated with pelvic fracture,. Intraperitoneal injury (20%).
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Etiology Blunt trauma: 1. direct blow to abdomen (leading to intraperitoneal rupture). 2. Motor vehicle accidents, falls and industrial trauma ( usually extraperitoneal and associated with pelvic bone fracture). Penetrating bladder injuries: gunshot wounds and stab wounds. Iatrogenic injuries: The bladder is the urological organ that most often suffers iatrogenic injury, mainly during gynecologic and urologic procedures.
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Presentation Gross hematuria is the cardinal sign ( associated with 90% of bladder injuries). Hematuria with pelvic fracture indicates bladder injury until proved otherwise. Lower abdominal pain, distention and tenderness ( extraperitoneal). Inability to urinate or difficulty in voiding. Acute abdomen (severe abdominal pain, distention and rigidity) with intraperitoneal rupture.
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Diagnosis Plain X-ray of the abdomen pelvic bone fracture, there may be haziness over the lower abdomen from blood and urine extravasation.. retrograde Cystography; is the investigation of choice for diagnosis and classification of bladder injury. CT cystogram. Foly’s catheterization is contraindicated if there is bladder at the meatus ( Urethral injury)..
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Extrapertoneal rupture shows a flame-shaped density adjacent to right lateral wall of bladder
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Intraperitoneal rupture extraluminal contrast (red arrows) outside the confines of the normal bladder and spreading into the peritoneal cavity. There is contrast in the left paracolic gutter (yellow arrow), not within the bowel. The intrarenal collecting systems and ureters are visualized because the patient had a contrast enhanced CT done moments earlier
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Treatment Intraperitoneal rupture; should be treated immediately with laparotomy and repair of the bladder. Extraperitoneal rupture ; treatment is usually by folly's catheterization ( for 7-14 days) and antibiotic cover. If there is an extensive urinoma or development of infection or bone fragment penetrating the bladder then surgical repair.