GOOD MORNING

RENAL TRAUMA PRESENTATION BY:

RAJESH.M

2nd YEAR MSC NURSING

CITY COLLEGE OF NURSING,

SHAKTINAGAR,MANGALORE

Renal trauma

The kidney is injured in approximately 10% of all significant blunt abdominal trauma.  Of those, 13% are sports-related when the kidney, followed by testicle, is most frequently involved. However, the most frequent cause by far is motor vehicle accident followed by falls.

Renal trauma

CausesAKI can be caused by disease, crush injury, contrast agents, some antibiotics, and more.The causes of acute kidney injury are

commonly categorized into prerenal, intrinsic, and postrenal.

Prerenal causes of AKI ("pre-renal azotemia") are those that decrease effective

 blood flow to the kidney. These include systemic causes, such as low blood volume, low blood pressure, heart failure, and local changes to the blood vessels supplying the kidney.

Prerenal

The latter include renal artery stenosis, or the narrowing of the renal arterywhich

supplies the kidney with blood, and renal vein thrombosis, which is the formation

of a blood clot in the renal vein that drains blood from the kidney.

Renal ischaemia ultimately results in functional disorder, depression of GFR, or both.

These causes stem from the inadequate cardiac output and hypovolemia or vascular diseases causing reduced perfusion of both kidneys. Both kidneys need to be affected as one kidney is still more than adequate for normal kidney function.

IntrinsicSources of damage to the kidney itself are

dubbed intrinsic. Intrinsic AKI can be due to damage to the glomeruli, renal tubules, orinterstitium. Common causes of each are glomerulonephritis, acute tubular necrosis (ATN), and acute interstitial nephritis (AIN), respectively. A cause of intrinsic acute renal failure is tumor lysis syndrome

PostrenalPostrenal AKI is a consequence of 

urinary tract obstruction. This may be related to benign prostatic hyperplasia, kidney stones, obstructed urinary catheter, bladder stone, bladder, ureteral or renal malignancy. It is useful to perform a bladder scan or a post void residual to rule out urinary retention. In post void residual, a catheter is inserted immediately after urinating to measure fluid still in the bladder.

50-100ml suggests neurogenic bladder. A renal ultrasound will demonstrate hydronephrosis if present. A CT scan of the abdomen will also demonstrate bladder distension or hydronephrosis, however, in case of acute renal failure, the use of IV contrast is contraindicated. On the basic metabolic panel, the ratio of BUN to creatinine may indicate post renal failure.

Commonly in men than in women

Commonly in younger than 30 yrs

incidence

---bruises or hemorrhage under renal capsule and collecting system intact

Contusion

bruises or hemorrhage under renal capsule and collecting system intact

Minor lacerationSuperficial disruption of the cortex,renal medulla,and collecting system not invoved

Major lacerationParenchymal disruption extending to cortex and medulla involving collecting duct

Fractured kidney

Shattered rupture

Vascular injury

Tear to renal artery or vein

Hematuria-cardinal manifestation

Serious renal injury can occur without hemarrhage

ShockFlank pain

Paralytic ileus

A palpable mass in the affected flank area or over the 11th and 12th rib

Clinical manifestation

Bruises over clients flank and lower back secondary to reteroperitoneal hemorrhage called as grey turners sign

contrast-enhanced, computed tomography (CT)

Investigation

History collectionPhysical examinationKUB filmIVPRetrograde pyelographyRenal scanUltrasonographyCT scan, MRIRenal angiography

Diagnostic evaluation

Urine analysis for RBCHematocrit value

EARLY DETECTIONThe deterioration of renal function may be

discovered by a measured decrease in urine output. Often, it is diagnosed on the basis ofblood tests for substances normally eliminated by the kidney: urea and creatinine. Both tests have their disadvantages. For instance, it takes about 24 hours for the creatinine level to rise, even if both kidneys have ceased to function.

. A number of alternative markers has been proposed (such as NGAL, KIM-1, IL18 and cystatin C), but none are currently established enough to replace creatinine as a marker of renal function.

Sodium and potassium, two electrolytes that are commonly deranged in people with acute kidney injury, are typically measured together with urea and creatinine.

Ureteral trauma•Penetrating trauma and unintentional injury during surgery•Gun-shot wound---95%•No specific signs and symptoms•Discovered during exploratory surgeries•If not detected urine leakage continues, fistula may develop•90% detected using intravenous urography•Surgical repair with placement of stents

Bladder trauma

Occur with pelvic fracture and multiple trauma or blow to the lower abdomen when the bladder is full

Contusion is resulted and evident as echymosis

Rupture of bladder can be extraperitoneally and intreperitoneally

Urethral traumaUsually occur with blunt trauma to lower abdomen or pelvic region

Classic triad of symptom comprises blood at the urinary meatus,inability to void and a distended bladder

TreatmentUnlike ultrasound examination (FAST), CT

provides anatomic and functional information that allows for accurate grading of the injury which is partly responsible for a growing trend toward conservative management (intravenous fluids, close monitoring, watchful waiting) of renal trauma.

 Conservative management does not apply in situations where extensive urinary extravasation or devitalized areas of renal parenchyma are found and especially if associated with injuries to other abdominal organs;

There are two primary mechanisms of injury when it comes to blunt abdominal trauma, and they are either compression or deceleration injuries.

Compression injuries are those that occur from direct “blows” against a fixed object (lap belt, spinal column, steering wheel) or a penetrating object. It is the transient pressure from these crushing injuries that cause tears and sub-capsular hematomas to the solid organ viscera (Liver and Spleen). These forces can also cause an intra-luminal pressure increase to hollow organs causing them to rupture (Small Bowel).

Pathophysiology

Deceleration forces between relatively fixed and free objects cause more of a shearing or tearing type of injury. Classic longitudinal shearing injuries usually rupture supporting structures to solid and hollow organs and include; a hepatic tear (along the ligamentum teres), injuries to the renal arteries and mesenteric tears. 

Diagnostic Peritoneal LavageDiagnostic Peritoneal Lavage (DPL) is performed when intra-abdominal bleeding secondary to trauma is suspected. The procedure is performed when CT or ultra-sound are not available or when the patient is too unstable and time is of the essence. The following is a step by step approach to performing a DPL:

Using local anesthesia, the surgeon makes a small incision in the abdomen just below the umbilicus

A cannula is inserted in the incision and is used to penetrate the midline fascia of the abdominal wall

During insertion, a sudden give or "pop" can be felt as the cannula passes through the fascia

A catheter is introduced through the incision into the abdomen

Saline is infused into the abdomen through the catheter, and then removed

If blood or intestinal contents are present in the saline after removal, it is highly probable that there is a serious intra-abdominal injury.

Positive DPL findings include:Bloody Lavage FluidRed Blood Cells > 100,000 cells/mmWhite Blood Cells > 500 cells/mmAmylase > 175 U/100 mlThe presence of any of the following is considered

a positive DPL:BacteriaFecal MaterialBileFood Products

Nursing Assessment/Documentation of the Patient with Blunt Abdominal Trauma Includes:

Appearance (distention, ecchymosis, lap belt signs, abrasions, wounds)

Auscultation (bowel sounds, bruits)Tenderness (guarding, rebound pain)Palpation (organomegaly, pulsating masses)

Signs of Peritonitis include:Abdominal pain (that increases with movement)Abdominal rigidityAbdominal guardingAbdominal distentionDiminished or absent bowel soundsFeverChillsNausea/VomitingAnorexiaShallow respirations (associated with pain)Tachycardia

Nursing Care and Management of the Patient With Blunt Abdominal Trauma Includes:

Monitor Vital signs/Respiratory status/Pain assessment

Routine Labs (notify physician of trends/abnormal values)

CBC (special attention to WBC’s and HgB/Hct)ElectrolytesFoley Catheter (can be used for intra-abdominal

pressure monitoring)Urine output (check for hematuria with kidney

injury)

Complete and ongoing abdominal assessmentPt. should remain NPO until surgical

intervention is ruled outNG to low continuous suctionIV or nutritional supportSequential or Ted hose

Post-op patient family education:Incision site care (signs and symptoms of

infection)Pain ManagementWork/Exercise/Rest balanceDietPrescriptionsFollow-up care

Loss of function of renal tissuesHigh risk of sepsis leading to kidney and

perinephric abscessesSecondary hemorrhageHypertension resulting from fibrosis and

ischemic kidneyRenal artery thrombosisArteriovenous aneurysmsFistula formation from extravasation of urineUrinomaspseudocysts

Complication

MANAGEMENT

Assess the condition of patient checking urine for rbc,hematocrit and hb level in blood

Assess for oliguria and sign of hemorrhagic shock

In case of contusion of the kidney,healing may take place with conservative measures

If patient has microscopic hematuria and a normal intravenous urogram, out patient management is possible

Medical management

If gross hematuria or minor laceration is present.

patient is hospitalized-----complete bed rest until hematuria

clears-----antimicrobial medication to prevent

infection from perirenal hematoma or urinoma

patient with retroperitoneal hematomas may develop low-grade fever as absorption of clot take place

-blood transfusion if hematocrit value is low

Surgical management

Major laceration may be treated through surgical intervention or conservatively

Vascular injury require immediate exploratory surgery.The damaged kidney is removed.(nephrectomy)

In bladder trauma, immediate exploratory surgery is done and repair of the laceration, suprapubic drainage of the bladder and perivesical space and insertion of an indwelling urinary catheter.The patient may have gross bleeding for several days even after repair

Nursing management

Assess the condition of patientAssess pain, muscle spasm, swelling over flank

Monitor intake output chart,vitals, level of consciousness

Opoid analgesics are avoided because it may mask abdominal symptoms

Catheterise patient after urethrography to minimize the risk of uretheral disruption and extensive, long term complication such as stricture, incontinence and impotence

Adequate fluid intakeGuideline for increasing activity gradually

lifting and driving are also provided in accordance with the physicians prescription.

Restrict activities for one month to avoid secondary bleeding

Advice to schedule periodic follow-up assessment of renal function

If nephrectomy was done patient is adviced to wear medical identification

Nursing Diagnosis:Alteration in Comfort: PainAlteration in Nutrition Potential for InfectionAltered Breathing PatternImmobilityKnowledge Deficit related to follow up care