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Case 330

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A 28-year-old male motorcyclist suffered a high-speed collision with a truck. His physical examination, in accordance with ATLS guidelines, is as follows: A: patent airway, cervical collar in place. B: Decreased breath sounds in the left hemithorax. C: HR: 135 bpm. SBP > 90 mmHg. Capillary refill time < 2”. Weak peripheral arterial pulses. Tender abdomen painful to palpation with no peritoneal irritation signs. D: Glasgow Coma Scale: 15. Isocoric photorreactive pupils. E: Extensive left flank ecchymosis. FAST (Focused Assesment with Sonography for Trauma) demonstrated no free fluid. A computed tomography scan was ordered.

Based on the depicted images, clinical scenario and the ASST (American Association for the Surgery of Trauma) renal injury scale, the patient’s kidney injury can be classified as:

a) Grade IV kidney injury

25%

b) Grade V kidney injury

25%

c) Grade II kidney injury

25%

d) Grade III kidney injury

25%
   

Image analysis

 

Image 1: Contrast-enhanced computed tomography (CT) scan, arterial phase, axial section at the level of the kidneys. Note the abscence of left kidney contrast enhancement (red circle). Compare with the right kidney for a normal enhancement pattern.

 

 

Image 2: Contrast-enhanced computed tomography (CT) scan, arterial phase, axial section at the level of the kidneys. Note the abscence of left kidney contrast enhancement (red circle). Compare with the right kidney for a normal enhancement pattern.

Highlights

– Kidney injury occurs in 43% of all traumas affecting the urinary system;

– Biomechanical mechanisms of trauma most often involved are: deceleration, flank blunt trauma and penetrating injury to the renal region;

– Ecchymosis and/or flank pain, rib fractures and macroscopic hematuria suggest kidney trauma;

– Contrast-enhanced CT scan is the method of choice in the evaluation, classification and definition of management of kidney trauma;

– Conservatite treatment is indicated in hemodynamically stable patients with minor to moderate injuries.

References

- Buckley J, McAninch J. Revision of Current American Association for the Surgery of Trauma Renal Injury Grading System. The Journal of Trauma: Injury, Infection, and Critical Care. 2011;70(1):35-37.

- Voelzke B. UpToDate [Internet]. Uptodate.com. 2018 [cited 19 August 2018]. Available from: https://www.uptodate.com/contents/management-of-blunt-and-penetrating-renal-trauma;

- Advanced Trauma Life Support. Chicago, IL: American College of Surgeons; 2018.

- Moore, E., Feliciano, D. and Mattox, K. Trauma. 8th ed. McGraw-Hill Education; 2017.

- Moore E, Shackford S, Pachter H, Mcaninch J, Browner B, Champion H et al. Organ Injury Scaling. The Journal of Trauma: Injury, Infection, and Critical Care. 1989;29(12):1664

Authors

Bernardo Bahia Finotti, 6th year medical student at UFMG.

Mail: bernardofinotti[at]gmail.com

Bernardo Gontijo Correa, 6th year medical student at UFMG.

Mail: bernardoiev[at]gmail.com

Supervisor

Dr. Evandro Luis de Oliveira Costa, adjunct professor at the Department of Surgery of the Faculty of Medicine of UFMG.

Mail: eloc[arroba]uai.com.br

Reviewers

Ariádna Andrade, Thiago Ruiz, William Alves, professor José Nelson Mendes Vieira, professor Viviane Santuari Parisotto Marino.

Translated by

Lucas Bruno Rezende, 6th year medical student at UFMG

 

Test question

(Unified Health System – São Paulo)

A 35-year-old car crash victim is brought to the Emergency Department. His physical examination is as follows: A: Orotracheal intubation. B: Breath sounds bilaterally present. SpO2 98%. C: HR: 110 bpm. BP: 100/70 mmHg. Capillary refill time: 2”. Stable pelvis, digital rectal exam with no abnormalities. D: Glasgow Coma Scale: 3. E: Multiple back injuries. Gross hematuria observed through urinary (Foley) catheter. What is the best management option?

a) Retrograde urethrocystography

25%

b) Bladder irrigation

25%

c) Diagnostic laparoscopy

25%

d) FAST (Focused Assessment With Sonography for Trauma)

25%

e) Computed tomography scan of the abdomen

25%
   

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