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2. RENAL TRAUMA
PRESENTATION BY:
RAJESH.M
2nd YEAR MSC NURSING
CITY COLLEGE OF NURSING,
SHAKTINAGAR,MANGALORE

4.  The kidney is injured in approximately 10% of all
significant blunt abdominal trauma. Of those,
13% are sports-related when the kidney, followed
by testicle, is most frequently involved. However,
the most frequent cause by far is motor vehicle
accident followed by falls.

6.  Causes
 AKI can be caused by disease,
 crush injury,
 contrast agents,
 some antibiotics, and more.
 The causes of acute kidney injury are commonly
categorized into prerenal, intrinsic, and postrenal.

9.  Prerenal causes of AKI ("pre-renal azotemia") are those
that decrease effective
 blood flow to the kidney. These include systemic
causes, such as low blood volume, low blood
pressure, heart failure, and local changes to the blood
vessels supplying the kidney.

10.  The latter include
 renal artery stenosis,
 or the narrowing of the renal arterywhich supplies the
kidney with blood, and
 renal vein thrombosis, which is the formation of
a blood clot in the renal vein that drains blood from
the kidney.

11.  Renal ischaemia ultimately results in functional
disorder, depression of GFR, or both.
 These causes stem from the inadequate cardiac output
and hypovolemia or vascular diseases causing reduced
perfusion of both kidneys. Both kidneys need to be
affected as one kidney is still more than adequate for
normal kidney function.

12.  Intrinsic
 Sources of damage to the kidney itself are
dubbed intrinsic. Intrinsic AKI can be due to damage
to the glomeruli, renal tubules, orinterstitium.
Common causes of each are glomerulonephritis, acute
tubular necrosis (ATN), and acute interstitial
nephritis (AIN), respectively. A cause of intrinsic acute
renal failure is tumor lysis syndrome

13.  Postrenal
 Postrenal AKI is a consequence of urinary
tract obstruction. This may be related to benign
prostatic hyperplasia, kidney stones,
obstructed urinary catheter, bladder stone, bladder,
ureteral or renal malignancy. It is useful to perform a
bladder scan or a post void residual to rule out urinary
retention. In post void residual, a catheter is inserted
immediately after urinating to measure fluid still in
the bladder.

14.  50-100ml suggests neurogenic bladder. A renal
ultrasound will demonstrate hydronephrosis if
present. A CT scan of the abdomen will also
demonstrate bladder distension or hydronephrosis,
however, in case of acute renal failure, the use of IV
contrast is contraindicated. On the basic metabolic
panel, the ratio of BUN to creatinine may indicate post
renal failure.

15.  Commonly in men than in women
 Commonly in younger than 30 yrs

16.  ---bruises or hemorrhage under renal capsule and
collecting system intact
bruises or hemorrhage under renal capsule
and collecting system intact

17. Superficial disruption of the cortex,renal
medulla,and collecting system not
invoved

18. Parenchymal disruption extending to
cortex and medulla involving collecting
duct

19. Shattered rupture

20. Tear to renal artery or vein

21.  Hematuria-cardinal manifestation
 Serious renal injury can occur without hemarrhage
 Shock
 Flank pain
 Paralytic ileus
 A palpable mass in the affected flank area or over
the 11th and 12th rib

22. Bruises over clients flank and lower
back secondary to reteroperitoneal
hemorrhage called as grey turners
sign

23.  contrast-enhanced, computed tomography (CT)

24.  History collection
 Physical examination
 KUB film
 IVP
 Retrograde pyelography
 Renal scan
 Ultrasonography
 CT scan, MRI
 Renal angiography

25.  Urine analysis for RBC
 Hematocrit value

28.  EARLY DETECTION
 The deterioration of renal function may be discovered
by a measured decrease in urine output. Often, it is
diagnosed on the basis ofblood tests for substances
normally eliminated by the
kidney: urea and creatinine. Both tests have their
disadvantages. For instance, it takes about 24 hours for
the creatinine level to rise, even if both kidneys have
ceased to function.

29.  . A number of alternative markers has been proposed
(such as NGAL, KIM-1, IL18 and cystatin C), but none
are currently established enough to replace creatinine
as a marker of renal function.
 Sodium and potassium, two electrolytes that are
commonly deranged in people with acute kidney
injury, are typically measured together with urea and
creatinine.

30. •Penetrating trauma and unintentional
injury during surgery
•Gun-shot wound---95%
•No specific signs and symptoms
•Discovered during exploratory surgeries
•If not detected urine leakage continues,
fistula may develop
•90% detected using intravenous urography
•Surgical repair with placement of stents

31. Occur with pelvic fracture and multiple trauma
or blow to the lower abdomen when the bladder
is full
Contusion is resulted and evident as echymosis
Rupture of bladder can be extraperitoneally
and intreperitoneally

32. Usually occur with blunt trauma to
lower abdomen or pelvic region
Classic triad of symptom comprises
blood at the urinary meatus,inability to
void and a distended bladder

33.  Treatment
 Unlike ultrasound examination (FAST), CT provides
anatomic and functional information that allows for
accurate grading of the injury which is partly
responsible for a growing trend toward conservative
management (intravenous fluids, close monitoring,
watchful waiting) of renal trauma.

34.  Conservative management does not apply in
situations where extensive urinary extravasation or
devitalized areas of renal parenchyma are found and
especially if associated with injuries to other
abdominal organs;

35.  There are two primary mechanisms of injury when it
comes to blunt abdominal trauma, and they are either
compression or deceleration injuries.
 Compression injuries are those that occur from direct
“blows” against a fixed object (lap belt, spinal column,
steering wheel) or a penetrating object. It is the
transient pressure from these crushing injuries that
cause tears and sub-capsular hematomas to the solid
organ viscera (Liver and Spleen). These forces can also
cause an intra-luminal pressure increase to hollow
organs causing them to rupture (Small Bowel).

36.  Deceleration forces between relatively fixed and free
objects cause more of a shearing or tearing type of
injury. Classic longitudinal shearing injuries usually
rupture supporting structures to solid and hollow
organs and include; a hepatic tear (along the
ligamentum teres), injuries to the renal arteries and
mesenteric tears.

37.  Diagnostic Peritoneal Lavage
Diagnostic Peritoneal Lavage (DPL) is performed
when intra-abdominal bleeding secondary to trauma
is suspected. The procedure is performed when CT or
ultra-sound are not available or when the patient is too
unstable and time is of the essence. The following is a
step by step approach to performing a DPL:

38.  Using local anesthesia, the surgeon makes a small
incision in the abdomen just below the umbilicus
 A cannula is inserted in the incision and is used to
penetrate the midline fascia of the abdominal wall
 During insertion, a sudden give or "pop" can be felt as
the cannula passes through the fascia

39.  A catheter is introduced through the incision into the
abdomen
 Saline is infused into the abdomen through the
catheter, and then removed
 If blood or intestinal contents are present in the saline
after removal, it is highly probable that there is a
serious intra-abdominal injury.

40.  Positive DPL findings include:
 Bloody Lavage Fluid
 Red Blood Cells > 100,000 cells/mm
 White Blood Cells > 500 cells/mm
 Amylase > 175 U/100 ml
 The presence of any of the following is considered a
positive DPL:
 Bacteria
 Fecal Material
 Bile
 Food Products

41.  Nursing Assessment/Documentation of the
Patient with Blunt Abdominal Trauma Includes:
 Appearance (distention, ecchymosis, lap belt signs,
abrasions, wounds)
 Auscultation (bowel sounds, bruits)
 Tenderness (guarding, rebound pain)
 Palpation (organomegaly, pulsating masses)

42.  Signs of Peritonitis include:
 Abdominal pain (that increases with movement)
 Abdominal rigidity
 Abdominal guarding
 Abdominal distention
 Diminished or absent bowel sounds
 Fever
 Chills
 Nausea/Vomiting
 Anorexia
 Shallow respirations (associated with pain)
 Tachycardia

43.  Nursing Care and Management of the Patient
With Blunt Abdominal Trauma Includes:
 Monitor Vital signs/Respiratory status/Pain
assessment
 Routine Labs (notify physician of trends/abnormal
values)
 CBC (special attention to WBC’s and HgB/Hct)
 Electrolytes
 Foley Catheter (can be used for intra-abdominal
pressure monitoring)
 Urine output (check for hematuria with kidney injury)

44.  Complete and ongoing abdominal assessment
 Pt. should remain NPO until surgical intervention is
ruled out
 NG to low continuous suction
 IV or nutritional support
 Sequential or Ted hose

45.  Post-op patient family education:
 Incision site care (signs and symptoms of infection)
 Pain Management
 Work/Exercise/Rest balance
 Diet
 Prescriptions
 Follow-up care

46.  Loss of function of renal tissues
 High risk of sepsis leading to kidney and perinephric
abscesses
 Secondary hemorrhage
 Hypertension resulting from fibrosis and ischemic kidney
 Renal artery thrombosis
 Arteriovenous aneurysms
 Fistula formation from extravasation of urine
 Urinomas
 pseudocysts

48.  Assess the condition of patient checking urine
for rbc,hematocrit and hb level in blood
 Assess for oliguria and sign of hemorrhagic
shock
 In case of contusion of the kidney,healing may
take place with conservative measures
 If patient has microscopic hematuria and a
normal intravenous urogram, out patient
management is possible

49.  If gross hematuria or minor laceration is
present.
patient is hospitalized
-----complete bed rest until hematuria clears
-----antimicrobial medication to prevent
infection from perirenal hematoma or
urinoma

50. patient with retroperitoneal hematomas may
develop low-grade fever as absorption of clot take
place
-blood transfusion if hematocrit value is low

51. Surgical management

53. Major
laceration may
be treated
through
surgical
intervention or
conservatively

54. Vascular injury
require
immediate
exploratory
surgery.
The damaged
kidney is
removed.(neph
rectomy)

55.  In bladder trauma, immediate exploratory
surgery is done and repair of the
laceration, suprapubic drainage of the
bladder and perivesical space and insertion
of an indwelling urinary catheter.The
patient may have gross bleeding for several
days even after repair

57.  Assess the condition of patient
 Assess pain, muscle spasm, swelling over
flank
 Monitor intake output chart,vitals, level
of consciousness

58.  Opoid analgesics are avoided because it may
mask abdominal symptoms
 Catheterise patient after urethrography to
minimize the risk of uretheral disruption and
extensive, long term complication such as
stricture, incontinence and impotence

59.  Adequate fluid intake
 Guideline for increasing activity gradually lifting and
driving are also provided in accordance with the
physicians prescription.
 Restrict activities for one month to avoid secondary
bleeding

60.  Advice to schedule periodic follow-up assessment of
renal function
 If nephrectomy was done patient is adviced to wear
medical identification

61.  Nursing Diagnosis:
 Alteration in Comfort: Pain
 Alteration in Nutrition
 Potential for Infection
 Altered Breathing Pattern
 Immobility
 Knowledge Deficit related to follow up care