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A 19-year-old builder is brought to casualty after falling 40 ft off scaffolding. He is unconscious and unable to give any further history. You are in the resuscitation room in a major trauma centre in a large city in the UK. You are asked to provide a urology opinion.
1. What are the principles of managing this patient?
This patient should be assessed according to advanced trauma life support (ATLS) principles. He should be assessed as part of the multi-disciplinary trauma team. A primary survey using the ABCDE algorithm should be performed. ABCDE should be performed sequentially looking at Airway (with C spine control) Breathing, Circulation (with haemorrhage control), Disability, Exposure/Environment.
On the primary survey you find he is maintaining his own airway, with a normal respiratory rate, his heart rate is 120 bpm and his blood pressure is 85/55. There is bruising to his right flank. He has no external sources of haemorrhage and his Glasgow Coma Scale (GCS) is now 12. After 2 L intravenous fluids his blood pressure normalises.
2. What imaging might you ask for in resus?
A ‘trauma series’ is often asked for alongside the primary survey. This comprises a cervical spine X-ray, a chest and pelvic X-ray.
His trauma series reveals no cervical spine fractures, lung contusions bilaterally and no pelvic fractures. You insert a catheter and 350 mL of blood-stained urine is drained. You are sent to discuss further imaging requirements with the on-call radiologist.
3. The radiologist asks what scan you would like and why?
You would ask for a specialised CT abdomen with contrast known as a three-phase renal CT, this images the arterial supply, the venous drainage and the excretory phase, looking for injuries to the renal vessels and the urine collecting system. Contrast is given intravenously and images are obtained at 15–30 seconds (arterial), 60–90 seconds (venous) and 10–15 minutes (urographic phase) after injection.
4. The CT is reported as showing a grade 3 renal injury. What grading system are they using? What does a grade 3 injury mean? He is still haemodynamically stable, and this is his only intra-abdominal injury, what is the likely management in this man’s case?
The most widely used grading system for renal trauma is that devised by the American Association for the Surgery of Trauma (AAST). This is a five-point grading scale where 1 is the least severe injury and 5 is the most severe. A grade 1 injury represents a contusion only or a non-expanding sub capsular haematoma, grade 2 is a laceration of the parenchyma <1 cm in size, grade 3 is a laceration >1 cm but not extending into the collecting system. The more severe injures are grades 4 and 5, where 4 represents an injury to a segmental renal vessel, or damage to the collecting system and grade 5 is a completely shattered kidney, or renal hillier injuries leading to a devascularised kidney. In this case, management is likely to be conservative, and consist of a period of bed rest, prophylactic antibiotics, close observation monitoring and re-imaging.
He recuperates quickly, and his haematuria settles spontaneously. A repeat CT scan at 48 hours shows resolution of his peri-renal haematoma. When he is ready to be discharged home, the trauma team looking after him ask whether you would like to follow him up as an outpatient.
5. Do you think this patient requires urology follow-up? Why? What things would you look for at follow-up?
The guidelines produced by the European Association of Urology state that patients should be seen in outpatients within 3 months of injury and should have the following investigations: physical examination, urinalysis, repeat imaging (ultrasound, CT or nuclear imaging depending on the patient), blood pressure measurement, and serum creatinine. Long-term follow-up schedules are not formalised, but can be required in certain cases.