IF... | THEN... | |
---|---|---|
Diagnosis | Blunt trauma + GH | Obtain CTU |
Blunt trauma + MH + SBP < 90 | ||
Blunt trauma concerning for renal injury but no hematuria | ||
Penetrating trauma near kidney with(out) hematuria | ||
Exam (rib fx, flank bruising) concerning for renal injury | ||
Unstable patient taken to OR without imaging | Obtain on table IVP 2mL/kg contrast bolus XR 10-15min later |
|
MH, no hypotension, no concerning injury | Can observe without imaging | |
Management | Grade I-III injury | Manage conservatively |
Grade IV-V injury | Repeat CT within 48hrs | |
Fever | ||
Worsening flank pain | ||
Worsening anemia | ||
Abdominal distension | ||
Expanding urinoma with:
|
Provide GU drainage Stent preferred Can consider PCN or drain |
|
Urinary extravasation without above signs | Can manage conservatively | |
Hemodynamically unstable not responding to resuscitation | Absolute indication for embolization/exploration | |
Hemodynamically unstable + perirenal hematoma > 4cm or Grade 3-5 injury with contrast extravasation | ||
Expanding/pulsatile renal hematoma | ||
Suspected vascular pedicle avulsion | ||
UPJ avulsion | ||
Urine extravasation with significant parenchymal devascularization | Relative indication for embolization/exploration | |
Renal + colon/pancreas injuries | ||
Arterial thrombosis | ||
Urine extravasation from parenchymal injury |
AAST ureteral injury severity, from AAST + Campbell's
Algorithm for ureteral injury from external trauma, from Campbell's
Algorithm for iatrogenic ureteral injury discovered intraoperatively, from Campbell's
Algorithm for iatrogenic ureteral injury discovered postoperatively, from Campbell's
IF... | THEN... | |
---|---|---|
Diagnosis | Ureteral injury suspected (see renal criteria) | CT urography |
Assessing for intraoperative injury | Inspect ureter Inject dye IV or via renal pelvis Contrast evaluation |
|
Management | Stable + contusion or crush injury | Place stent Debride if large injury |
Stable + intraop laceration | Place stent Repair laceration |
|
Unstable + intraop injury | Ligate ureter with nonabsorbable stitch Place PCN or cutaneous ureterostomy +/- stent Delayed repair |
|
Delayed identification:
|
Retrograde pyelogram + stent placement If fails, place PCN Delayed repair |
|
Ureterovaginal fistula | Stent (64-76% success) Delayed repair (100% success) |
IF... | THEN... | |
---|---|---|
Diagnosis | Pelvic fracture + gross hematuria | Retrograde cystography |
Penetrating injury to butt, pelvis, lower abdomen + any hematuria | ||
Management | Intraperitoneal injury | Immediate surgical repair |
Pelvic fracture + bone fragments in bladder | ||
Simultaneous rectal/vaginal injury | ||
Bladder neck injury | ||
Laparotomy for non-bladder reasons | ||
Inadequate drainage or clots | ||
Penetrating trauma | ||
Extraperitoneal injury | Catheter x2-3 weeks (avoid exploration if possible to prevent severe bleeding) | |
Prolonged catheterization required | Consider suprapubic tube placement | |
Neurologic injuries | ||
Orthopedic injury + immobility | ||
Complex bladder closure | ||
Iatrogenic endoscopic injury | Extraperitoneal perforation | Catheter drainage |
Small intraperitoneal perforation without:
|
Catheter drainage + antibiotics | |
Large intraperitoneal perforation | Surgical repair | |
Small intraperitoneal perforation with above criteria | ||
Extraperitoneal perforation failing to heal |
IF... | THEN... | |
---|---|---|
Diagnosis | Blood at meatus | Immediate retrograde urethrogram Do not place catheter before RUG |
Pelvic fracture | ||
Bladder rupture | ||
Genital/perineal hematoma | ||
Penile fracture | ||
High-riding prostate | ||
Penetrating penile injury | ||
Distended bladder | ||
Management | Partial urethral disruption | Attempt catheter placement once Then place SPT |
Penetrating anterior injury | Consider immediate repair if able Delay if unstable, extensive tissue loss, or lack of experience |
|
Pelvic fracture + urethral injury | Place SPT (preferred options) Primary repair if rectal/bladder neck injury present |
|
Straddle injury | Place urethral or SP catheter | |
Penile fracture with urethral injury | Immediate repair |