Emergency Department Care
Adherence to ATLS principles is necessary for proper care of the trauma patient.
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Administer oxygen and provide ventilatory support if needed.
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Resuscitate with crystalloids (lactated Ringer solution or isotonic sodium chloride solution) and blood (O-negative or type-specific blood if known) if indicated.
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Treat life-threatening injuries (eg, tension pneumothorax, open pneumothorax, cardiac tamponade) emergently in the ED.
Assess capabilities of the ED to handle the patient with multiple injuries that include upper GU trauma; decide whether to transfer based on that assessment.
Treat life-threatening injuries prior to transfer; stabilize and resuscitate the patient.
The transferring physician is responsible for the decision to transfer, the choice of transfer modality, and selection of an accepting facility.
The receiving physician confirms the ability of the receiving institution to handle the patient's condition.
Institutional transfer protocol facilitates the process.
Patients with upper GU trauma benefit from transfer when the following conditions exist at the transferring center:
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CT scan is not available.
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No staff urologist is present.
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Multiple injuries surpass the care that hospital resources can provide.
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Specialized care required for patient injuries is unavailable.
Consultations include the following:
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Trauma or general surgeon for management of associated abdominal injuries
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Urologist for management of specific GU injuries
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Other specialists as injuries dictate
Outpatient care depends upon associated injuries and the need for rehabilitation (eg, orthopedic injuries, neurologic injuries).
Follow-up CT scan is indicated in patients with renal injuries to assess the progress of healing; IVP is required as follow-up care for ureteral repairs.
Insert a Foley catheter only after urethral injury is excluded. Consider performing a suprapubic cystostomy in a percutaneous or open manner when a Foley catheter is contraindicated or when it cannot be inserted and urine output measurement or detection of hematuria is required.
Prehospital care
Advancement of prehospital care for trauma patients is one of the biggest leaps forward in trauma care. Principles do not change with different organ injuries.
Paramedics quickly assess the patient and mechanism of injury, with special attention to patency of ABCs.
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Establish an airway if needed and/or administer oxygen.
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Establish 2 large-bore IVs.
Cervical spine precautions (eg, hard collar, backboard) should be taken.
The patient should be quickly transported to the trauma center.
Medical Care
Grade of Injury
Management of renal injuries depends on the grade of the injury and is linked to management of associated injuries. [21, 22] Grade of renal injury is best depicted in the scale developed by the American Association for the Surgery of Trauma (see below). [23, 24, 25]
Grades I, II, and III injuries should be treated conservatively. Vital signs, hematocrit level, and progression of hematuria should be monitored. Most patients heal without intervention. Rarely, radiologic selective embolization is needed to control hematuria that does not subside spontaneously.
In grade IV injuries, expectant treatment of extravasation has a 60% success rate if ureteral outflow is not impeded. Flow obstruction can be corrected with stenting. If urinary extravasation does not improve, percutaneous drainage should be performed. Vascular injury indicates surgical intervention for repair, provided warm ischemia time does not exceed 4 hours. Hemorrhage control also indicates surgical exploration. [26]
Most children with grade IV renal injuries are treated by a conservative approach with a high success rate, but some may require urologic intervention because of symptomatic urinomas. According to one study, the need for transfusion and the presence of specific image features on initial CT (eg, main laceration location in the anteromedial portion of kidney), intravascular contrast extravasation, and a large perinephric hematoma may serve as useful predictive factors for urologic intervention in grade IV pediatric blunt renal trauma patients who were initially treated by a conservative approach. [27]
In grade V injuries, completely shattered kidneys require excision for control of hemorrhage. Kidneys with pedicular avulsion do not require removal unless a laparotomy already is being performed for a different pathology. Avulsed kidneys do not result in late sequelae if left in situ. Revascularization of the kidney should be attempted only if warm ischemia time is less than 4 hours, as failure rates are extremely high when warm ischemia time is more than 4 hours. High rates of infection and hypertension occur in kidneys with failed revascularization. Exceptions should be made for patients with solitary kidneys and decreased renal capacity. [28]
Management of acute ureteral injury primarily involves repair. Debridement is performed until a healthy bleeding ureter is reached; repair is performed at this point by the surgeon. The type of repair depends on the level of ureter injury and the length of ureter lost to injury and debridement. [29]
Treatment of ureteropelvic junction injuries requires reimplantation of the ureter into the renal pelvis. Ureteroureteral or ureterovesicular anastomoses are used for distal injuries; bladder flaps may be required for a tension-free anastomosis. Transureteroureterostomy (anastomosis of the injured ureter to the contralateral ureter) has lost favor because of associated danger to the normal ureter. Management of missed ureteral injuries includes drainage of urinomas (preferably percutaneously) with a nephrostomy. Inflammation is allowed to subside (3-6 wk), then a definitive surgical repair is performed.
Most children with grade IV/V renal injury following blunt trauma can be managed nonoperatively. Management can be properly planned and executed based on clinical features, CT imaging, and staging of renal injuries. [30]
Grade I
Contusion - Microscopic or gross hematuria with normal urologic studies
Hematoma - Subcapsular, nonexpanding injury without parenchymal laceration
Grade II
Hematoma - Nonexpanding injury confined to the renal retroperitoneum
Laceration - Less than 1 cm parenchymal depth of renal cortex without urinary extravasation
Grade III
Laceration - More than 1 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation
Grade IV
Laceration - Injury extending through renal cortex, medulla, and collecting system
Vascular injury - Main renal artery or vein injury with contained hemorrhage
Grade V
Laceration - Completely shattered kidney
Vascular injury - Avulsion of renal hilum that devascularizes the kidney
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Ruptured left kidney.
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Avulsed left renal artery with thrombosis.
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CT scan of abdomen and pelvis showing a urinoma.
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Urinoma by CT.
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Lateral view of a urinoma.
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Contrast-filled urinoma.
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Retrograde urethrogram showing a leak in the distal right ureter with an element of obstruction.
