a whack to the flank….

the case.

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.

[DDET What are your principles of management in this case ?]

  • 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.
    • E-FAST.
    • 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.
  • Analgesia.
    • Titrated intravenous opiates.
    • Likely to require PCA.
  • Preparation/expectation for warfarin reversal.
    • Prothrombinex.
    • Vitamin K.
    • Fresh frozen plasma.
    • Consideration of tranexamic acid if requiring massive transfusion.
  • Assess for potential medical reasons for ‘fall’.
    • ie. was this syncope ?
    • ECG
  • Seek and treat less significant traumatic injuries.
    • Secondary survey.
    • CT-Brain + C-spine.
    • X-rays dictated by physical exam.
  • Others:
    • Family notification.
    • Consider tetanus booster + prophylactic antibiotics.


[DDET What happens next ??]

Whilst the team are seeing to the primary survey & getting IV access, you obtain the following images on your bedside FAST exam…

RUQ view
RUQ view



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….


[DDET Here is his CT scan…]


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.


[DDET The diagnosis ??]


  • 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.

Ultrasound [FAST].

  • High sensitivity & specificity for free-fluid.
  • Misses up to 78% of known renal injuries.
  • Will not identify renal vascular injury.

Indications for Imaging [suspected renal injury]

Advanced imaging.
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.
    • 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 Traumatic Renal Injury

Schematics of Renal Injury grades ~ Courtesy of onsurg.com

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
  • Urinoma
  • Perinephric abscess
  • HTN


  • 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.


[DDET References.]

  1. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  3. Renal Trauma – Trauma.org
  4. Renal Trauma Grading – Radiopaedia.org


Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.