Case conference

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Case conference

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• ????? ??

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Case conference

• ????,7 y/o girl
• 90?12?25? 23pm
• ???,????
• C.C ????,????,??
• AVPU, PR 120/min, RR 18/min,
• BP115/58?102/57mmHg, BW20kg

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Present illness

• Fall down by herself at 1230PM, hit on the
  chair, severe left flank pain was noted.
• Then gross hematuria was noted, accompanied by
  intermittent abdominal pain, so she was brought
  to ER for help.

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Past history

• Denied any major disease.
• Denied take any drug, including herbs.

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Physical examination

• Conscious alert
• HEENT grossly normal
• Chest Heart rate 120/min, breath sound clear
• Abdomen soft, no ecchymosis, left side abdomenal
  tenderness, left flank area tenderness
• Extremities grossly normal

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Impression

• Left kidney contusion with internal bleeding.
• Order list
• N/S 300cc st. then 60cc/hr (245pm)
• CBC, biochemistry
• Prepare blood
• On BP, EKG monitor
• CXR, KUB

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continued

• Order list
• Keto ½ Amp iv (320pm)
• Abd CT with contrast
• N/S 400cc st (335pm)
• On Foley
• On critical
• Sent pt to PICU-17 (410pm)

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Lab data

• 90-12-25 331pm
• Glu 158
• GOT 45
• BUN 16
• Cr 0.5
• Na 141
• K 3.5

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Lab data

• 90-12-25 344pm
• WBC 19.7 K/ul (seg/lym 72.5/19.9)
• RBC 4.17 million
• Hb 11.6
• MCV 81.1
• RDW 13.0
• Plt 335

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CT (90-12-25)

• A deep corticomedullary laceration of the left
  lower pole kidney. Fragmentation of the left
  kidney highly suspected. Extensive perirenal
  hemorrhage.
• Renal hilum seems preserved.
• Abnormal fluid collection over left anterior
  pararenal space.
• Spleen is intact.

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PICU

• 90-12-25 abdomenal echo
• Clinical diagnosis left kidney laceration, R/O
  tumor rupture
• Description
• Edematous and swelling of pancreatic body (size
  1.4)
• Minimal ascites at LLQ area and Douglas pouch
• Well capsulated heterogeneous mass at LUQ
• Displacement of left kidney and suspect of
  disruption of lower pole of left kidney.
• The left kidney 9.7cm, right kidney 6.17cm

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PICU

• Close monitor vital sign and conservative
  treatment.
• Bed rest until no gross hematuria, restrict
  exercise up to 6 weeks.
• Prophylatic antibiotics.
• IVP 1 week later

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IVP

• Enlargement of left renal shadow.
• Normal opacification of left upper and middle
  calyces.
• Extravasation of contrasted urine over the left
  lower pole kidney.
• Non-visualized left ureter.
• Normal opacification of right urotract and UB.

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PICU

• Operation is indicated if
• Perirenal abscess formation
• Uncontrollable bleeding
• Urinoma
• Collecting system injury

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PICU

• Vital sign stable and condition stable transfer
  to ward at 2002-12-28
• Hematuria off and on grossly.
• IVP arranged at 2002-1-5

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Progress note

• Abdomenal echo (2001-12-31)
• No ascites noted.
• A myxomatous mass like lesion above the left
  psoas muscle at LUQ are, the size is 4x2x2cm
• A linear laceration of lower pole of left kidney,
  minimal fluid accumulation in subcapsule.

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IVP (2002-1-4)

• Enlargement of left renal shadow
• Extravasation of contrast over the left lower
  pole kidney
• Non visualized left ureter
• Normal right urinary tract
• Well distended urinary bladder

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Operation note

• OP was arranged at 2002-1-10
• Left nephrorraphy and drainage of hematoma
  urine with CVW drain tube insertion.

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Post-OP care

• Pain control
• Antibiotics for 4 weeks
• CWV drain care and monitor the amount of drainage
• Discharged and OPD follow up at 2002-1-15.

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OPD

• IVP 2002-1-28
• Kidney echo 2002-2-9
• Heterogeneous echogenicity, partial separation
  and scarring of lower pole of kidney.
• Kidney echo 2002-3-4
• Ditto
• F/u 6 months later.

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Blunt abdominal trauma with kidney injury
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Background

• In children, the most common cause of death is
  accident.
• Craniocerebral trauma is the leading cause of
  death in accidents.
• If blunt abdominal trauma is encountered, the
  liver and spleen are the most injuried organ.
• 8-10 will be kidney injury.

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Kidney injury

• Renal contusion (gt90)
• Renal laceration (5)
• Renal pedicle injury (2)
• Renal rupture (shattered kidney) (1)
• Renal pelvis rupture (lt1)

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OIS of kidney injury
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Tools

• Diagnostic peritoneal lavage (DPL) until 1984
• Ultrasonography (starting in 1980)
• Urinalysis
• Excretory urography (IVP)
• CT with intravenous contrast agent
• Conventrional and digital subtraction angiography
• MRI angiography

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Kidney injury

• For initial evaluation, urinalysis has provide to
  be very reliable in detecting injury to the
  kidneys. For example

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Kidney injury

• However, Stein et al and Zwergel did not observe
  hematuria in all cases of kidney injury.
• Disruption of the ureter or the renal pedicle
  present without hematuria.

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Kidney injury

• Degree of hematuria does not correlate with
  severity of injury.
• A combination of 5 largest series evaluating 2739
  pts with blunt renal trauma, normotension and
  microscopic hematuria identified 3 (0.1) with
  significant renal injury.
• Radiographic evaluation may not needed in the
  normotensive blunt trauma pt with microscopic
  hematuria. Several institutions routinely perform
  CT or IVP in this setting.

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Sono vs. CT

• Although Akgur et al were able to make the
  correct diagnosis in most cases by sono, Krupnick
  et al, Rossi et al, and Haftel et al advocated
  for immediate CT scan because they found that
  sono was not accurate enough which can only
  detect around 70 of the lesions.

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IVP vs. CT

• The abdominal contrast-enhanced CT is to be
  favored either initially or in the further
  evaluation of kidney injuries. For example

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Radiographic assessment

• Penetrating flank or abdominal trauma.
• Gross hematuria with blunt abdominal trauma.
• Microscopic hematuria with blunt abdominal
  trauma.
• Hypotension.
• Any degree of hematuria in pediatric pts.

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Treatment

• The investigators changed their concept of
  immediate intervention in favor of expectant
  management combined with minimal invasive
  techniques as draining urinomas percutaneously.
• Excluding a shattered kidney or a renal pedicle
  injury, it was possible to treat all pts
  nonoperatively for 48 to 72 hrs, even in grade 3
  and 4 lesions.

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Treatment

• In patients who present with a major renal
  laceration associated with devascularized
  segments, conservative management is feasible in
  those who are clinically stable with blunt
  trauma.
• Bju International. 87(4)290-4, 2001 Mar.

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Management

• Immediate abdominal sono as screening. If the pt
  is hemodynamically stable and further
  life-threatening injuries are excluded, a more
  meticulous exam is possible.
• Initial urinalysis
• If an injury grade 3 or higher is suspected, an
  immediate CT scan with IV contrast should be
  performed.

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Management

• If excretion of contrast agent into the renal
  collecting system is absent, MRI angiography, or
  otherwise digital subtraction angiography should
  be performed.
• Lesions up to grade 3 should be treated
  nonoperatively. A mandatory surgical approach
  begins at grade 4, if possible as a minimal
  invasive intervention after stabilizing the
  circulatory conditions.

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Indications for operation

• Uncontrolled renal hemorrhage
• Penetrating injuries
• Inadequate staging
• Multiple kidney lacerations
• Shattered kidney
• Avulsed major renal vessel
• Pulsatile or expanding hematoma found on
  abdominal exploration
• Extensive extravasation
• Vascular injuries

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Thank you for your attention!!