an 84 year old man is bought to your emergency department following a 3 metre fall from a ladder. He has landed on his right-hand side & is complaining of severe bilateral chest & flank pain.
His systolic blood pressure with the paramedics has been 100-105 mmHg, except for a transient episode of hypotension [72mmHg systolic] which resolved after a 300mL bolus of crystalloid. On arrival to ED he has a GCS of 15, full recollections of events & no focal neurological deficit but is in excruciating pain.
Pulse 66/min. BP 106/72. SaO2 94%. RR 26.
He is on warfarin for atrial fibrillation, but does not recall his last INR measurement.
- Rapid assessment [Primary survey] & concomitant treatment of life threatening injuries.
- Multidisciplinary approach. Trauma call. Resuscitation bay.
- Includes empiric C-spine immobilisation [mechanism, age, distracting injuries]
- Rapid detection of early evidence of haemorrhage.
- Pelvic x-ray.
- Early CT-scan including arterial-phase if remains ‘stable’.
- Preparation for massive transfusion.
- Multiple possible injuries each with potential for massive blood loss.
- Minimum of 2x large-bore cannula.
- Cross-matched blood.
- Titrated intravenous opiates.
- Likely to require PCA.
- Preparation/expectation for warfarin reversal.
- Vitamin K.
- Fresh frozen plasma.
- Consideration of tranexamic acid if requiring massive transfusion.
- Assess for potential medical reasons for ‘fall’.
- ie. was this syncope ?
- Seek and treat less significant traumatic injuries.
- Secondary survey.
- CT-Brain + C-spine.
- X-rays dictated by physical exam.
- Family notification.
- Consider tetanus booster + prophylactic antibiotics.
Whilst the team are seeing to the primary survey & getting IV access, you obtain the following images on your bedside FAST exam…
Moderate amount of hypoechoic material in the RUQ ?blood+clot. This appears to be more in the perinephric space than ‘Morrison’s pouch’.
The remainder of the E-FAST is unremarkable.
The patient remains haemodynamically stable, however receives empiric reversal of his anticoagulation with 50IU/kg of prothrombin complex concentrates [Prothrombinex®], plus 10mg IV vitamin K. He is then taken rapidly to CT for further assessment….
Other positive findings included:
- Multiple rib fractures including left sided flail segment.
- Associated left pulmonary contusion.
- Fractures of T4 & T8.
- Comminuted fracture of right ilium plus left superior & inferior pubic rami.
- Right sacroiliac joint subluxation.
- Present in 8-10% abdominal trauma.
- Penetrating vs Blunt mechanisms
- Accounts for < 0.1% of trauma deaths.
- Rarely occurs in isolation.
- > 80% have additional visceral/skeletal injuries.
- Often non-urological injuries result in haemodynamic instability.
- Recall: the kidneys receive 20-25% of cardiac output [~1200mL per minute], therefore have potential for massive blood loss.
- No correlation between presence & absence of haematuria with severity of injury.
- ~14% of major injuries [& ~10% of minor injuries] have no haematuria.
- No correlation between degree of microscopic haematuria and severity of injury.
- Gross haematuria MAY correlate with severe renal injury.
- Can miss up to two-thirds of renal injuries if used in isolation.
- High sensitivity & specificity for free-fluid.
- Misses up to 78% of known renal injuries.
- Will not identify renal vascular injury.
Goals of imaging are to stage the injury, assess for preexisting renal pathology, functionality/disease-state of contralateral kidney & assess for concomitant traumatic injuries.
- CT with IV contrast.
- GOLD STANDARD.
- Delineates grade of injury [contusion, laceration, haematoma] + perfusion abnormalities.
- Contrast extravasation = active haemorrhage.
- Use of delayed scan [~10min post contrast administration] = ?urinary extravasation.
- IV urography.
- KUB-xray is taken ~10 minutes after an IV contrast bolus is administered.
- ↓ Sn in hypotensive/shocked patients.
- Does not aid in grading.
- Does have a role in on-table imaging if patient is taken straight to laparotomy for other reasons.
- Formal angiography.
- Allows for embolisation or stenting at initial assessment.
- Has role for further assessment for delayed injuries/pathology [ie. thrombosis, aneurysm formation].
GRADING OF RENAL INJURIES.
For further examples of renal injuries check out Radiopaedia.org
- Standard ‘Trauma-rules’ apply.
- Haemodynamic compromise → exploratory laparotomy.
- Majority of renal injuries [Grades I, II & III] can/will be managed conservatively.
- Some Grade IV injuries will too.
- Only ~9% of renal injuries require surgical exploration. Of these ~11% require nephrectomy.
- Indications for surgical intervention.
- Life-threatening haemorrhage.
- Expanding, pulsatile or non-contained retroperitoneal haematoma.
- Renal avulsion injury [Grade V]
- Renal pelvis or ureteric injuries DO require repair. Urinary extravasation is NOT a sole reason for exploration. These usually resolve spontaneously.
- Some injuries are amenable to stenting or angio-embolisation.
- Delayed bleeding
- usually secondary to AV-fistula formation [~25% of Grade III or IV injuries]
- Urinary extravasation
- Perinephric abscess
- The majority of patients will require admission for concomitant injuries.
- Patients with gross haematuria should be admitted & observed until it clears.
- Who can be discharged ?
- Patients with microscopic haematuria & no indications for imaging.
- Light duties only & close follow-up.