1. Renal trauma accounts for 1-5% of all traumas, with blunt trauma making up 90-95% of cases. Physical exam findings like hematuria or flank pain may indicate renal injury. 2. Non-operative management is recommended for most renal injuries. Stable patients with Grade I-IV injuries can be managed conservatively with bed rest, hydration, antibiotics and monitoring. 3. Computed tomography is the best imaging method for diagnosing and staging renal injuries in stable patients. Unstable patients may require angiography or intravenous pyelography.

1. RENAL
TRAUMA
AMBER Z JAFFERI
EMERGENCY DEPARTMENT
SIH

2. BACKGROUND
1-5% of all traumas
Male to female ratio 3:1
Mechanism is classified as blunt or penetrating
Blunt trauma accounts 90-95%
Traffic accidents accounts half of blunt renal injuries
Renal lacerations and renal vascular injuries make up only 10-
15% of blunt renal injuries

3. BACKGROUND
Renal artery occlusion is associated with a rapid deceleration
injuries
Rate of nephrectomy in recent wars is relatively high (25-33%)

4. INJURY
CALSSIFICATION
A total of 26 classifications have been presented in
the literature in the past 50 years
These are oriented to different criteria such as :
1. The pathogenesis ( blunt or penetrating )
2. The morphological findings ( type and degree of
lacerations )
3. The clinical course ( nature and time of
symptoms )

7. AAST RENAL INJURY GRADING
SCALEGrade Description of injury
1 Contusion or non-expanding subcapsular hematoma
No laceration
2 Non-expanding perirenal hematoma
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration > 1cm without urinary extravasation
4 Laceration : through corticomedullary junction in to collecting system
Or
Vascular : segmental renal artery or vein injury with contained hematoma
5 Laceration: shatered kidney
Or
Vascular : renal pedicle injury or avulsion

8. INITIAL EMERGENCY
ASSESSMENT
Securing of the airway
Controlling any of the external bleeding
Resuscitation of shock
Physical examination is carried out during stabilization

9. HISTORY AND PHYSICAL
EXAMINATION
Direct history is obtained from conscious patients
Witness and emergency personnel can provide information regarding
unconscious patients

10. POSSIBLE INDICATORS OF MAJOR RENAL
INJURY

11. The following findings on physical examination may indicate
possible renal involvement :
1. Hematuria
2. Flank pain
3. Flank ecchymosis
4. Flank abraisions
5. Fractured ribs
6. Abdominal distension
7. Abdominal mass
8. Abdominal tenderness

12. GUIDELINES ON
LABORATORY
EVALUATION
Urine from a patient with suspected renal
injury should be inspected grossly and then
by dipstick analysis
Serial hematocrit measurement indicates
blood loss ( renal or associated injuries ? )
Creatinine measurement reflects renal
function preior to the injury

13. GUIDELINES ON RADIOGRAPHIC
ASSESSMENT
Blunt trauma patients with macroscopic or
microscopic hematuria ( at least 5 rbc/hpf ) with
hypotension (systolic blood pressure < 90 mmHg )
should undergo radiographic evaluation
Radiographic evaluation is also recommended for 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
Ultrasonography can be informaive during the
primary evaluation of polytrauma patients and for the
follow-up of the recuperating patients

14. GUIDELINES ON
RADIOGRAPHIC
ASSESSMENT
A CT scan with enhancement of intravenous contrast material is the
best imaging study for diagnosis and staging renal injuries in
hemodynamically stable patients
Unstable patients who require emergency surgical exploration
should undergo a one-shot IVP with bolus intravenous injection of
2ml/kg contrast
Formal IVP , MRI , and radiographic scintigraphy are reliable
alternative methods of imaging renal trauma when CT is not available
Angiography can be used for diagnosis and simultaneous selective
embolization of bleeding vessels

15. COMPUTED TOMOGRAPHY SCAN OF RIGHT KIDNEY FOLLOWING STAB
WOUND LACERATION WITH URINE EXTRAVASATION , LARGE RIGHT
RETROPERITONEAL HEMATOMA

16. TREATMENT
Non-operative management is the treatment of choice for the
majority of renal injuries
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%

17. GUIDELINES ON MANAGEMENT
OF RENAL TRAUMA
Stable patients following grade 1-4 blunt
renal trauma , should be managed
conservatively :
Bed-rest , hydration and antibiotics , and
continuous monitoring of vita signs until
hematuria resolves
Stable patients , following grade 1-3 stab
and low velocity-gunshot wounds after
complete staging , should be selected for
expectant management

18. GUIDELINES ON MANAGEMENT
OF RENAL TRAUMA
Indications for surgical management include :
1. Haemodynamic instability
2. Exploration for associated injuries
3. Expanding or pulsatile perirenal hematoma identified
during laparotomy
4. A grade V injury
5. Incidental finding of pre-existing renal pathology
requiring surgical therapy
Renal reconstruction should be attempted in cases where
the primary goal of controlling hemorrhage is achieved
and sufficient amount of renal parenchyma is viable

19. GUIDELINES ON POST-
OPERATIVE MANAGEMENT AND
FOLLOW-UP
Repeat imaging is recommended for all hospitalized patients within
2-4 days following renal trauma
Nuclear scintigraphy before discharge from the hospital is useful
for documenting functional recovery
Within 3 months of major renal trauma , patients follow-up should
involve :
1. Physical examination
2. Urinalysis
3. Individualized radiological investigation
4. Serial blood pressure measurement
5. Serum determination of renal function
Long-term follow-up should be decided on a case-by-case basis

24. COMPLICATIONS
Early complications :
Bleeding , infection , perinephric abscess ,
sepsis , urinary fistula , hypertension , urinary
extravasation and urinoma
Delayed complications :
Bleeding , hydronephrosis , calculus formation ,
chronic pyelonephritis , hypertension ,
arteriovenous fistula , and psuedoaneurism

25. GUIDELINES ON MANAGEMENT
OF COMPLICATIONS
Complication following renal trauma
require a thorough radiographic evaluation
Medical management and minimal invasive
techniques should be the first choice for
the management of complications
Renal salvage should be the aim of surgeon
for patients in whom surgical intervention
is necessary

27. GUIDELINES ON MANAGEMENT OF PAEDIATRIC
TRAUMA
Indications for radiographic evaluation of children suspected for
renal trauma include :
1. Blunt and penetrating trauma patients with any level of
hematuria
2. Patients with associated abdominal injuries regardless of the
urinalysis findings
3. Patients with normal urinalysis who sustained a rapid
deceleration events , direct flank trauma , or fall from height
Ultrasonography is considered a reliable method of screening and
following blunt renal injuries
CTscans is the imaging study of choice for staging renal injury
Haemodynamic instability and a diagnosed grade V injury are
absolute indications for surgical exploration

29. GUIDELINES ON MANAGEMENT OF
POLYTRAUMA PATIENTS WITH
ASSOCIATED RENAL INJURY
Polytrauma patients with associated renal
injuries should be evaluated on the basis of
the most threatening injury
In cases where the decision for surgical
intervention is made , all associated
injuries should be evaluated
simultaneously
The decision for conservative management
should regard all injuries independently