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Flashcards in Renal Trauma Trevor Deck (26)
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1

Why are children more susceptible to trauma-based kidney injuries?

Children have larger overalls kidneys compared to body size

Children have less perirenal fat

Lower ribs are incompletely ossified

2

What is the most common cause of genitourinary trauma?

Blunt force trauma

*degree of hematuria does not correlate with degree of injury*

3

Structures in upper and lower urinary tracts

Upper tract:
- kidneys
- ureters

Lower tract:
- bladder
- urethra
- genitalia

4

Why should you check the urethral meatus during pelvic trauma?

If there is blood in the urethral meatus, you need to be careful placing a folly catheter since you could cause more damage to a urethral injury

5

Are ureters likely to be damaged in blunt trauma?

NO they are well protected
- most is penetrating trauma

6

What is the most common cause of damage to the bladder?

**Blunt trauma and pelvic fractures**

Bladder is only likely to rupture if the bladder is full and there is injury to the lower abdomen

7

Why is the male urethra more prone to injury

It’s long and less mobile compared to the female

8

Urethrogram/cystogram

Injecting contrast material into the distal urethra to check injury of the urethra and/or bladder
- leakage or improper filling of the bladder can indicate urethral injury

9

Indications for retrograde urethrogram (RUG)

Patient unable to void after pelvic trauma

Physical exam signs concerning for urethral injury

Blood at urethral meatus

Scrotal hematoma

Ecchymoses of perineum

Prostate displacement on rectal exam

10

How to treat generalized uncomplicated lower tract renal injuries?

Extraperitoneal injuries = Foley catheter and time
- just manage, nothing invasive

Intraperitioneal injuries = ** need surgery

11

What is the imaging study of choice for the upper urinary tract?

#1 = CT scan of the abdomen and pelvis with IV contrast
- IVP is 2nd choice

**cystogram is lower urinary tract**

12

What is the definitive treatment for pelvis fractures with hemorrhage?

Pelvic placement via a pelvic cast

Also requires massive transfusion protocol with > 10 units of packed RBCs and both platelets andFPP at a ratio of 1:1:1

**this differs from osteoporosis adults**

13

When to decide to give packed RBCs?

Either:
1) Hemoglobin is <7 but is a euvolemic non trauma patient
2) Ongoing severe hemorrhage and unstable vital signs

**type O- blood is the universal donor blood, type AB plasma is the universal donor plasma**

*1 unit of pRBC = increases Hgb by 1 g/dL or Hct by 3%*

14

What is the typical transfusion rate for stable patients?

typical = 1 unit of pRBCs over 2 hrs

Level 1 rapid transfusion = 500ml/min

15

FFP vs Prothrombin complex concentrate (PCC)

PCC = contains Vitamin-K factors 2/7/9/10
- FFP does not have this

**FFP also has higher Volume than PCC which can be problematic in patients with edema/CHF

PCC is way more expensive (5000) than FFP (250)

16

What are counts to remember for platelet transfusions

<10,000 = give platelets everytime as prophylaxis

Major surgery and is 50,000 = give platelets

Active hemorrhage >50,000

CNS injuries >100,000

**even though its still used, if the patient has ITP or TTP the platelets and transfusions will be destroyed**

17

Tranexamic acid (TXA)

MOA: inhibits binding sites on plasminogen which prevents the breakdown of plasminogen -> plasmin

**essentially the opposite of tPA**

#1 in noncompressible hemorrhages or heavy uterine bleeding

18

Does the amount of blood from a urinary injury directly correlate with the degree of severity?

NO

19

When do you give FFP to a patient?

Hemorrhaging patient with a coagulopathy present
- requires type and screen to be ABO compatible

*also need to monitor PT/PTT*

20

TRALI

Transfusion related acute lung injuries
- 1:5000 incidence in patients who have transfused blood products

**Caused by neutrophils being sequestered in the micro vasculature of the lungs and then activation of the neutrophils causes releases of cytokines and ROS which damages pulmonary capillary endothelium**

Symptoms: “all occur within 6hrs of transfusion”
- hypoxemia
- fever
- hypotension**
- cyanosis
- respiratory distress

21

TACO

Transfusion associated circulatory overload
- presents as a reaction to blood transfusions that develops Pulmonary edema due to volume overload
- * high risk in patients with underlying cardiovascular or renal diseases

Symptoms: “all present within 6-12hrs after infusion”
- respiratory distress
- Hypertension**
- headaches
- seizures (rare)
- wide pulse pressure
- S3 heart sound on auscultations
- wheezes/rales on auscultation

22

Evaluation of direct kidney trauma

CT scan w/ IV contrast = #1

Most dont require surgical intervention and just require outpatient (grade 1-2) or admission (grade 3) with symptomatic and palliative care

**if a grade 4 or 5 with devascularization of the kidney or grade 1-3 with persistence of urine leakage = needs surgery**

23

Should digital rectal exams be used to diagnosis urethral or prostate injuries?

NO
- often times the prostate cant be felt properly due to pelvic hematomas (which are common in these injuries)

digital recital exams should be focused solely on detecting rectal injuries

24

What are common complications of urethral injuries?

Urethral strictures

Urinary incontinence

Erectile dysfunction (from either neurogenic or vasogenic)

25

What are the 4 views of a fast exam?

Right upper quadrant = Morrison’s pouch

Left upper quadrant = splenomegaly recess

Subxiphoid = looking for hemopericardium

Pelvic = rectovesical/rectouterine pouch

26

Treatment of spleen injuries

If hemodynamically stable with grade 1-3 spleen injuries (no vasculature damage)
- if hemodynamically unstable or grade 4 is present = splenectomy

Avoid splenectomy if possible!!