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Renal tract trauma

August 10, 2017

You've picked up a competitor from the track following a collision that occurred on the exit of a high speed turn. He's now at the medical centre and has begun to complain of flank pain. He's certainly pretty tender over his right lower ribs posteriorly and on further examinations there's a little bit of blood where wee usually comes out.

Eeek! He might have blunt renal tract trauma.

Luckily, you've just been to this website and read through the material below. Having taken care of the core resuscitation, here's the low-down on renal tract trauma.


Anatomy

Renal - Ureters - Bladder - Urethra
Relatively protected due to the retroperitoneal anatomy.


Mechanism

More commonly blunt or deceleration mechanism (These are our patients).
Typically falls, motor vehicle collisions and straddle injuries.

Clues include:
  • Lower rib fractures
  • Flank pain, tenderness or bruising
  • Low T or L-spine fractures
  • Pelvic ring fractures, especially AP compression (pubic diastasis, pubic rami butterfly fracture)
  • Haematuria - Microscopic haematuria is generally not indicative of significant injury and is usually ignored. Macroscopic haematuria needs investigation. 5% of renal injuries produce no haematuria.


Blunt Kidney Injury

Kidney injury needs a little extra information, so here you are:



Management of renal trauma

Surgeons are generally reluctant to operatively explore renal trauma as it is associated with 65% incidence of subsequent nephrectomy regardless of intent of the exploration. Non-operative management is increasingly preferred even for high grade injuries.

The evidence base for management recommendations is poor, consisting mainly of retrospective analyses and single centre studies.

Ongoing evolution of approaches and techniques, with increasing controversy proportional to the grade of injury. There are significant differences in the imaging choices, management approach and interventional techniques used by trauma surgeons and urologists (See the referenced article at the end).

Interventional radiology, endovascular techniques and cystoscopic approaches are constantly evolving.

Generally agreed that key indications for operative management are:
  • Haemodynamic instability (usually associated with other intra-abdominal injuries)
  • Renal pelvic avulsion - usually results in nephrectomy
  • Expanding, non-contained haematoma.
However, this too is evolving.

With increasing non-operative management, the role of the routine follow-up CT 4-6 days post injury also causes controversy.
  • One paper showed the incidence of operative management was <1% for blanket routine follow-up CT and around 20% when selected for clinical indication.
  • A second paper showed no complications occurred if the initial injury Grade was I-III or the patient was assymptomatic.
  • Again, retrospective analyses rather than RCTs.
So there you go. This may not change what you do at the track or circuit in terms of interventions, but maybe your index of suspicion and trauma referral practice might go up a notch or two.


References
  1. Haematuria in trauma - https://lifeinthefastlane.com/ccc/haematuria-in-trauma/
  2. Evaluation of Hematuria in Blunt Trauma - http://regionstraumapro.com/post/1601798416/hematuria
  3. Thoughts On Traumatic Hematuria: Part 1 - http://regionstraumapro.com/post/163906343900/thoughts-on-traumatic-hematuria
  4. AAST Revises Renal Injury Grading - http://regionstraumapro.com/post/2909024096
  5. Renal trauma - http://www.trauma.org/archive/abdo/renal/intro.html
  6. Management of blunt renal injury - what is new?. Eur J Trauma Emerg Surg (2015) 41:251–258
  7. Contemporary management of renal trauma - Differences between urologists and trauma surgeons. AAST 2011 PLENARY PAPER. J Trauma Volume 72, Number 1, Pg 68-77.




 

Bikes, motorsport and life

May 1, 2017

I like to think that I am not totally unfit. I attribute much of that to spending most of my younger years cycling everywhere and swimming a lot. I think it gave me a good base to work from.

I'm getting older and bits of me creak now. What is more noticeable is the longer recovery time. I've become more aware of my physical limitations and how they can impact on how I choose to spend my life. I figure that if I am going to be able to continue doing the things that I enjoy and particularly kee...

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ICMS AGM 2016 - Intro and Day 1

February 24, 2017

This conference was great. It was what a motorsport conference covering safety, medical and rescue issues should be. No topic was off limits, no presenter was protected from being challenged (and most audience challenges stuck to the rules of engagement), invited speakers were from a broad range of backgrounds (gender, profession, motorsport category and geography) and most appealing of all, there was a general air of desire to promote and progress improved understanding and practice.


(I don't...

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A tonic for the C-spine collar haterade

February 24, 2017

I've been drinking from that fountain. Semi rigid c-spine collars have been receiving a drubbing in recent times (Search the c-spine collar tag over to the right of this page). And with good reason, I thought; though I will admit to not being quite ready to throw them away completely as I have been a long time practicioner of avoiding the "always/never" ultimatum.


Then trauma master, Karim Brohi, Professor of Trauma Sciences at Barts and the London School of Medicine, and Consultant in Trauma...

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FIA Institute CMO Seminar - Day 2

January 6, 2017

The Christmas and New Year holidays are over and having spent some enjoyable time with the family poncing about, it's time to get back to work. Here is my summary of Day 2 of the FIA Institute Medicine in Motorsport CMO seminar held as part of the FIA AGA in Vienna at the beginning of December.

The first half of the day was composed of an opening speech by Jean Todt (which I missed) and four workshops. After lunch there were five free papers presented followed by the closing speech. After a so...

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FIA Institute CMO Seminar 2016 - Day 1

December 14, 2016


Two weeks ago I was sitting in an apartment in the middle of the Vienna Naschmarkt, having flown in at 6am that morning from Australia to attend the biennial FIA Institute Medicine in Motorsport Chief Medical Officer's seminar. Traditionally, while there are a handful of exceptions, this is a fairly passive affair consisting of a series of talks and a couple of fairly didactic workshops (SMACC it is not).

Two years ago a small bonfire was lit when Dr Sean Petherbridge (CMO for the Abu Dhabi F...


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The crushing weight of evidence

September 21, 2016
It's interesting how things sometimes seem to come together at the same time for different reasons. I've been thinking about extrication recently in the setting of a competitor trapped by compression. That got me thinking about a talk given by Sydney HEMS doctor, Cliff Reid, titled "The wrong stuff" during which he went through some pre-hospital dogma bug-bears (bug-dogs?), including the management of crush injury/syndrome. At the same time of my pondering a tweet went out for a doctor in Ita...

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Flight after a pneumothorax

August 10, 2016

There have been a number of incidents at motorsport events that have resulted in a blunt chest injury mechanism with the competitor presenting to the event medical centre for assessment and while no major injuries were found they have subsequently been diagnosed with a pneumothorax. Usually it has been a small one, associated with one or more fractured ribs, diagnosed on a CT. Some of the more high profile incidents include:


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How to do simulation training well

August 9, 2016
The previous blog post covered a recent session that I ran for some Australian Rally Championship competitors which covered First On Scene Response training. The aim of the session was to give the competitors some basic skills so that should they be the first to arrive at a rally accident where someone has been seriously injured they have a framework to get help and provide some potentially life or limb saving assistance, buying time for the medical team. The session was deliberately practica...

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An untapped rescue resource for rally and off-road events

June 2, 2016
Last week I finished up a clinical week in the ICU and went home. Just like this time last year, I packed my bags after putting my kids to bed and early on Friday morning, before they woke up, I got into my car and drove three hours to Canberra for the National Capital Rally. This time, however, I had a few extra bags and boxes.

There is a requirement for motorsports, like many other events, to have medical cover in case of illness or injury. At circuit races a medical crew can be at a crash...


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