Upper Urinary Tract Trauma: Difference between revisions

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=== Epidemiology ===

* Most commonly injured GU organ in trauma

* '''Most commonly injured GU organ in trauma'''

=== Pathogenesis ===

* Kidneys are particularly prone to deceleration injuries (e.g. falls, motor vehicle collisions) because they are fixed in space only by the renal pelvis and the vascular pedicle

* '''Kidneys are particularly prone to deceleration injuries (e.g. falls, motor vehicle collisions) because they are fixed in space only by the renal pelvis and the vascular pedicle'''

* The pediatric kidney is believed to be more susceptible to trauma

* '''The pediatric kidney is believed to be more susceptible to trauma'''

** Mechanisms owing to a decrease in the physical renal protective mechanisms found in children (4):

** '''Mechanisms owing to a decrease in the physical renal protective mechanisms found in children (4):'''

**# Immature, more pliable thoracic cage

**# '''Immature, more pliable thoracic cage'''

**# Weaker abdominal musculature

**# '''Weaker abdominal musculature'''

**# Less perirenal fat

**# '''Less perirenal fat'''

**# Sits in a lower abdominal position

**# '''Sits in a lower abdominal position'''

=== Diagnosis and evaluation ===

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===== History =====

* Most important information in blunt renal injury is the extent of deceleration involved in high-velocity impact trauma

* '''Most important information in blunt renal injury is the extent of deceleration''' involved in high-velocity impact trauma

* Trauma to the anterior axillary line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury

* '''Trauma to the anterior axillary line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury'''

===== Physical exam =====

* Findings indicating possible renal injury (5):

* '''Findings indicating possible renal injury (5):'''

# Flank hematoma

# '''Flank hematoma'''

# Abdominal or flank tenderness

# '''Abdominal or flank tenderness'''

# Rib fractures

# '''Rib fractures'''

#* Ipsilateral rib fracture can increase the incidence of significant renal trauma by 3x

# Penetrating injuries to the low thorax or flank

# '''Penetrating injuries to the low thorax or flank'''

# Hematuria

# '''Hematuria'''

#* The degree of hematuria and the severity of the renal injury do not consistently correlate; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma

#* '''The degree of hematuria and the severity of the renal injury do not consistently correlate'''; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma

==== Imaging ====

* Indications

* '''Indications'''

** AUA: indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):

** '''AUA: indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):'''

**# Gross hematuria

**# '''Gross hematuria'''

**# Microscopic hematuria and systolic blood pressure < 90mmHG

**# '''Microscopic hematuria and systolic blood pressure < 90mmHG'''

**# Mechanism concerning for renal injury (e.g., rapid deceleration, significant blow to flank)

**# '''Mechanism concerning for renal injury (e.g., rapid deceleration, significant blow to flank)'''

**# Physical exam findings concerning for renal injury (e.g. rib fracture, significant flank ecchymosis)

**# '''Physical exam findings concerning for renal injury (e.g. rib fracture, significant flank ecchymosis)'''

**# Penetrating injury of abdomen, flank, or lower chest

**# '''Penetrating injury of abdomen, flank, or lower chest'''

*** Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.

*** '''Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.'''

**Campbell’s indications for imaging (similar to AUA indications but worded differently)

**#All blunt trauma with gross hematuria

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**#All pediatric patients with greater than 5 RBCs/HPF

* Modality

* '''Modality'''

** CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury (AUA)

** '''CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury''' (AUA)

*** In children, ultrasound may be used, although CT is preferred

*** An intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without preliminary CT scan if surgeons are considering renal exploration or nephrectomy

*** Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.

*** '''Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.'''

**** A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury

**** '''A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury'''

* CT findings suspicious for significant renal injury include (6):

* '''CT findings suspicious for significant renal injury include (6):'''

*# Medial laceration

*# '''Medial laceration'''

*# Medial hematoma (vascular pedicle injury)

*# '''Medial hematoma (vascular pedicle injury)'''

*# Medial urinary extravasation (renal pelvis or ureteropelvic junction injury)

*# '''Medial urinary extravasation (renal pelvis or ureteropelvic junction injury)'''

*# Hematoma > 3.5cm

*# '''Hematoma > 3.5cm'''

*# Lack of contrast enhancement of the parenchyma (main renal arterial injury)

*# '''Lack of contrast enhancement of the parenchyma (main renal arterial injury)'''

*# Active intravascular contrast extravasation (arterial injury with brisk bleeding)

*# '''Active intravascular contrast extravasation (arterial injury with brisk bleeding)'''

* '''Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):'''

~~CT scan showing left renal artery injury (source: Wikipedia)~~

# '''Hematomas''' - density is almost always > 30 HU

# '''Urinomas''' - density ranges from 0-20 Hounsfield units (HU)

* Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):

# '''Abscesses''' - associated with rim enhancement; perinephric abscess rarely occurs after renal injury

# Hematomas - density is almost always > 30 HU

# Urinomas - density ranges from 0-20 Hounsfield units (HU)

# Abscesses -associated with rim enhancement; perinephric abscess rarely occurs after renal injury

==== [https://www.aast.org/library/traumatools/injuryscoringscales.aspx#kidney AAST Grading] ====

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<nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III

What Grade of injury is this based on the AAST classification?

Source~~: Wikipedia~~

=== Management ===

@@ Line 16: / Line 16: @@
 === Epidemiology ===
-* Most commonly injured GU organ in trauma
+* '''Most commonly injured GU organ in trauma'''
 === Pathogenesis ===
-* Kidneys are particularly prone to deceleration injuries (e.g. falls, motor vehicle collisions) because they are fixed in space only by the renal pelvis and the vascular pedicle
+* '''Kidneys are particularly prone to deceleration injuries (e.g. falls, motor vehicle collisions) because they are fixed in space only by the renal pelvis and the vascular pedicle'''
-* The pediatric kidney is believed to be more susceptible to trauma
+* '''The pediatric kidney is believed to be more susceptible to trauma'''
-** Mechanisms owing to a decrease in the physical renal protective mechanisms found in children (4):
+** '''Mechanisms owing to a decrease in the physical renal protective mechanisms found in children (4):'''
-**# Immature, more pliable thoracic cage
+**# '''Immature, more pliable thoracic cage'''
-**# Weaker abdominal musculature
+**# '''Weaker abdominal musculature'''
-**# Less perirenal fat
+**# '''Less perirenal fat'''
-**# Sits in a lower abdominal position
+**# '''Sits in a lower abdominal position'''
 === Diagnosis and evaluation ===
@@ Line 34: / Line 34: @@
 ===== History =====
-* Most important information in blunt renal injury is the extent of deceleration involved in high-velocity impact trauma
+* '''Most important information in blunt renal injury is the extent of deceleration''' involved in high-velocity impact trauma
-* Trauma to the anterior axillary line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury
+* '''Trauma to the anterior axillary line is more likely to damage important renal structures such as the renal hilum and pedicle compared to the posterior axially line, which more commonly results in parenchymal injury'''
 ===== Physical exam =====
-* Findings indicating possible renal injury (5):
+* '''Findings indicating possible renal injury (5):'''
-# Flank hematoma
+# '''Flank hematoma'''
-# Abdominal or flank tenderness
+# '''Abdominal or flank tenderness'''
-# Rib fractures
+# '''Rib fractures'''
 #* Ipsilateral rib fracture can increase the incidence of significant renal trauma by 3x
-# Penetrating injuries to the low thorax or flank
+# '''Penetrating injuries to the low thorax or flank'''
-# Hematuria
+# '''Hematuria'''
-#* The degree of hematuria and the severity of the renal injury do not consistently correlate; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma
+#* '''The degree of hematuria and the severity of the renal injury do not consistently correlate'''; presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma
 ==== Imaging ====
-* Indications
+* '''Indications'''
-** AUA: indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):
+** '''AUA: indications for imaging (contrast enhanced CT with immediate and delayed films) in stable trauma patients (5):'''
-**# Gross hematuria
+**# '''Gross hematuria'''
-**# Microscopic hematuria and systolic blood pressure < 90mmHG
+**# '''Microscopic hematuria and systolic blood pressure < 90mmHG'''
-**# Mechanism concerning for renal injury (e.g., rapid deceleration, significant blow to flank)
+**# '''Mechanism concerning for renal injury (e.g., rapid deceleration, significant blow to flank)'''
-**# Physical exam findings concerning for renal injury (e.g. rib fracture, significant flank ecchymosis)
+**# '''Physical exam findings concerning for renal injury (e.g. rib fracture, significant flank ecchymosis)'''
-**# Penetrating injury of abdomen, flank, or lower chest
+**# '''Penetrating injury of abdomen, flank, or lower chest'''
-*** Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.
+*** '''Generally, children can be imaged using the same criteria as adults. Children, however, often do not exhibit hypotension as adults do.'''
 **Campbell’s indications for imaging (similar to AUA indications but worded differently)
 **#All blunt trauma with gross hematuria
@@ Line 66: / Line 66: @@
 **#All pediatric patients with greater than 5 RBCs/HPF
-* Modality
+* '''Modality'''
-** CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury (AUA)
+** '''CT abdomen/pelvis with IV contrast (with immediate and delayed images) should be performed when there is suspicion of renal injury''' (AUA)
 *** In children, ultrasound may be used, although CT is preferred
 *** An intraoperative one-shot IVP (2 mL/kg IV bolus of contrast with a single image obtained 10-15 minutes later) may be used to confirm that a contralateral functioning kidney is present in rare cases where the patient is taken to the operating room without preliminary CT scan if surgeons are considering renal exploration or nephrectomy
-*** Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.
+*** '''Major limitation of CT scan in renal trauma: inability to adequately define a renal venous injury adequately.'''
-**** A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury
+**** '''A medial hematoma strongly suggests a venous injury, however, there is no imaging modality which can accurately diagnose a venous injury'''
-* CT findings suspicious for significant renal injury include (6):
+* '''CT findings suspicious for significant renal injury include (6):'''
-*# Medial laceration
+*# '''Medial laceration'''
-*# Medial hematoma (vascular pedicle injury)
+*# '''Medial hematoma (vascular pedicle injury)'''
-*# Medial urinary extravasation (renal pelvis or ureteropelvic junction injury)
+*# '''Medial urinary extravasation (renal pelvis or ureteropelvic junction injury)'''
-*# Hematoma > 3.5cm
+*# '''Hematoma > 3.5cm'''
-*# Lack of contrast enhancement of the parenchyma (main renal arterial injury)
+*# '''Lack of contrast enhancement of the parenchyma (main renal arterial injury)'''
-*# Active intravascular contrast extravasation (arterial injury with brisk bleeding)
+*# '''Active intravascular contrast extravasation (arterial injury with brisk bleeding)'''
+[[File:Leftrenalarteryinjury.png|center|thumb|600x600px|CT scan showing left renal artery injury[[commons:File:Leftrenalarteryinjury.png|Source]]]]
+* '''Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):'''
-CT scan showing left renal artery injury (source: Wikipedia)
+# '''Hematomas''' - density is almost always > 30 HU
+# '''Urinomas''' - density ranges from 0-20 Hounsfield units (HU)
-* Differential diagnosis of fluid collections seen on serial imaging for renal trauma (3):
+# '''Abscesses''' - associated with rim enhancement; perinephric abscess rarely occurs after renal injury
-# Hematomas - density is almost always > 30 HU
-# Urinomas - density ranges from 0-20 Hounsfield units (HU)
-# Abscesses -associated with rim enhancement; perinephric abscess rarely occurs after renal injury
 ==== [https://www.aast.org/library/traumatools/injuryscoringscales.aspx#kidney AAST Grading] ====
@@ Line 94: / Line 92: @@
 <nowiki>*</nowiki>Advance one grade for bilateral injury up to grade III
+[[File:Abdotrauma.png|center|thumb|600x600px|What Grade of injury is this based on the AAST classification?[[commons:File:Abdotrauma.PNG|Source]]]]
-What Grade of injury is this based on the AAST classification?
-Source: Wikipedia
 === Management ===