Trauma and Fistulas Flashcards
(99 cards)
When should you order imaging (CT a/p with contrast immediate and delayed imaging) in a BLUNT trauma patient when you are concerned about renal trauma?
Guideline 1: You should order imaging in a stable patient with gross hematuria or who is unstable (systolic < 90) AND with microscopic hematuria (of any level).
In a child order CT for any child with gross hematuria or microscopic hematuria > 50 RBC/HPF (no need to be hypotensive)
What mechanism of injury should make you suspicious of renal injury, prompting you to order imaging (CT with contrast and with delayed imaging)?
Guideline 2: rapid deceleration injury, significant blow to flank, rib fractures, flank ecchymosis, or penetrating injury of abdomen, flank, or lower chest.
In hemodynamically stable patients with renal injuries, what is first line management?
Guideline 4: non-invasive management strategies including hemodynamic monitoring, serial H/H, reduced activity (possible bedrest).
How do you perform a one-shot IVP?
Inject 2 ml/kg contrast (150 ml max) into IV and take x-ray 10 minutes later
You can initially observe a stable patient with renal parenchymal injury. When is prompt intervention warranted?
Guideline 6: Endoscopic or open surgery is warranted when there is concern for renal pelvis or proximal ureteral avulsion is expected (see large medial urinoma with contrast extravasation and no distal ureteral contrast on delayed imaging.
When should you take a renal trauma patient to surgery?
Guideline 5: When they are hemodynamically unstable and fail to respond to resuscitation OR are hemodynamically unstable and have a large perirenal hematoma (> 4 cm), with a deep or complex renal laceration (grade 3-5 injury).
This can be surgery or angioembolization (if patient stable enough)
What is the 2018 AAST Renal injury grading system?
Grade 1: subcapsular hematoma, with or without laceration
Grade 2: superficial laceration < 1 cm, not involving the collecting system
perirenal hematoma confined to the perirenal fat
Grade 3: laceration > 1 cm, not involving the collecting system
vascular injury or active bleed confined to the perirenal fascia
Grade 4: any laceration involving the collecting system with urinary extravasation OR complete UPJ disruption OR vascular injury to a segmental renal artery or vein OR segmental infarction OR active bleeding beyond the fascia (in the retroperitoneum)
Grade 5: Shattered kidney OR avulsion of the renal hilum or laceration of the main kidney or vein causing devasularization OR devascularized kidney with active bleeding
What renal trauma patient needs follow up CT imaging in the hospital?
Guideline 7: AAST grade 4 or 5 OR signs of complications (fever, worsening flank pain, ongoing blood loss, abdominal distention)
What patient with a renal injury needs urinary drainage with a ureteral stent (which can be augmented with a perc neph and/or drain and/or foley) during observation?
Guideline 8: enlarging urinoma on follow up imaging, fever, increasing pain, ileus, fistula or infection
In what trauma patient should you suspect a ureteral injury?
Guideline 9: complex, multi system A/P trauma patients with complex fractures or rapid deceleration injury or high velocity GSW with trajectory near the ureter
You need delayed contrast imaging to detect ureteral injuries
In cases where imaging is not an option because the patient went straight to surgery, what should you do if you suspect a ureteral injury?
Guideline 10: directly inspect the ureters with an open approach or retrograde ureterogram. Do not do a IVP in this case- it does not look at the ureters well enough
If a ureteral injury is found in a stable patient, how should you proceed acutely?
Guideline 10: Repair the ureteral injury at the time of laparotomy, do not delay if the patient is stable
If a ureteral injury is found in an unstable patient, how should you proceed?
Guideline 10b: The patient is unstable, you need to clip the ureter to prevent extravasation and place a nephrostomy tube or externalize a ureteral catheter secured to the proximal defect.
How do you manage a ureteral contusion found in surgery?
Guideline 10c: You may choose to place a ureteral stent or you may choose to repair it primarily depending on viability and scenario- approach is up to surgeon
How do you manage an incomplete ureteral injury diagnosed postoperatively or in the delayed setting?
Guideline 11a: Recommended that you try to place a retrograde ureteral stent
Guideline 11b: If its not possible to pass a ureteral stent, place a percutaneous nephrostomy with delayed repair
How should you initially manage a ureterovaginal fistula?
Guideline 11c: Place a ureteral stent when possible, if this fails then you may consider surgical intervention (ureteral implantation).
Stent rates are highly successful in 65-100% of cases
How should you surgically repair a ureteral injury proximal to the iliac vessels?
Guideline 12a: a spatulated, tension free anastomosis over a ureteral stent is advised after all non-viable ureter as been removed
How should you surgically manage a ureteral injury distal to the iliac vessels?
Guideline 12b: you should manage with ureteral reimplantation or primary repair over a stent when possible. May require a boari flap or psoas hitch
How should you surgically manage an endoscopic ureteral injury?
Guideline 13a: Place a ureteral stent when possible. If this isn’t possible or fails to divert the urine, place a nephrostomy tube +/- periureteral drain unless
Guideline 13b: you may manage this with open repair if the above endoscopic measures fail to adequately divert the urine.
How should you manage a stable patient with gross hematuria and a pelvic fracture or a mechanism concerning for bladder injury such as pelvic ring fractures?
Guideline 14 a/b: You should perform a retrograde cystogram (either CT or plain film). You do this by letting contrast drain in by gravity through a foley to 300 ml or whenever patient is uncomfortable. Then take a plain film. Drain all the contrast and take one more plain film.
Urethra should be cleared first to allow for placement of a foley if needed
How should you manage intraperitoneal or extraperitoneal bladder injuries?
Guideline 15-17: Place a foley and let heal by itself in uncomplicated extraperitoneal bladder injuries
Perform surgical repair with 2 layer absorbable sutures in complicated extraperitoneal and intraperitoneal bladder injuries
Leave catheters in for 2-3 weeks and follow up cystography should be done to ensure the bladder injury has completely healed.
If an uncomplicated extraperitoneal bladder injury hasn’t healed by 4 weeks, you should consider taking the patient back for a formal bladder repair
After bladder repair, should you place a suprapubic tube for good urinary drainage?
Guideline 18: NO, suprapubic tubes are generally not required- a foley catheter is all that is needed
( of course there are exceptions to the above: urethral injury, poorly mobilizing persons, really complex bladder repairs or severe hematuria)
What should you do if you see blood at the urethral meatus after pelvic trauma?
Guideline 19: A retrograde urethrogram! (exception is gently trying to place a well-lubricated catheter if patient is unstable- must be single attempt and “experienced” team member only)
To do a retrograde urethrogram: place patient in oblique (if possible due to pelvic injuries) with foley or 60 ml luer lock syringe in meatus or foley with balloon filled with 1-2 ml water, with penis on stretch pass 20 ml undiluted contrast slowly into bladder
If a catheter was placed with blood at the urethral meatus, prior to removing the catheter, you should do a periurethral RUG.
What is the preferred management for pelvic fracture urethral injuries?
Guideline 20 a/b: This is placing a percutaneous or open suprapubic tube (14F or larger) and guidelines state this should be done promptly
Primary endoscopic alignment is associated with a longer clinical course
However, Guideline 22 says you can try primary realignment in stable patients but this attempt should not be prolonged (and again, not encouraged)
