Kidney trauma

Reviewed and revised 22 December 2015

OVERVIEW

  • Most genitourinary injuries are not immediately life-threatening
  • Renal pedicle injury can lead to life-threatening hemorrhage and renal ischemia

ASSESSMENT

Clinically significant injuries will have at least one of:

  • Macroscopic haematuria (About 5% of renal injuries and up to 20% of renovascular injuries lack even microscopic hematuria)
  • Loin tenderness and/ or swelling
  • Haemodynamic instability

Fracture of the lower posterior ribs, lower thoracic or lumbar vertebrae may also be present

Imaging

  • CT abdomen with IV contrast is the investigation of choice (injury severity is graded I to V)
  • IVP (intravenous pyelogram) is an option if CT is unavailable or imaging needs to be carried out in the operating theatre, but is less sensitive and does not visualize non-urologic injuries
  • Renal angiography is rarely required

GRADING

American Association for Surgery of Trauma Organ Injury Scale based on:

  • haematoma size (relation to capsule, size, expanding)
  • laceration size (parenchymal depth)
  • urinary extravasation
  • cortex, medulla and collecting system involvement
  • vessel involvement
  • integrity of kidney
  • vascular status
  • whether one or both kidneys involved

Grade       Description of Injury

I                   haematuria, no parenchymal involvement, subcapsular, normal urogram

II                 non-expanding, confined to retroperitoneum, < 1cm, no urinary extravasation

III                >1cm involving renal cortex (no urinary extravasation or collecting system involvement)

IV                 cortex, medullary and collecting system or vascular involvement

V                  shattered or an avulsed kidney

MANAGEMENT

  • ATLS approach
  • Urology consult
  • Most renal injuries (Grades I to III, and most Grade IV injuries) can be managed conservatively, as they tend to heal spontaneously
  • Surgical repair is needed for urinary extravasation or if ongoing bleeding or haemodynamic instability due to renal injury
  • Alternatives to operative repair are interventional radiology to embolise bleeding vessels or to stent dissected renal arteries, and urinary extravasation may be amenable to stenting
  • Grade V injuries (avulsed kidneys) need operative intervention and often require nephrectomy

Reference and Links

LITFL

FOAM and web resources


CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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