Blunt Trauma Abdomen (BTA) – Kidney Injury 

 Epidemiology & Importance

• Kidney = most commonly injured genitourinary organ in blunt trauma
• Seen in ~10–15% of abdominal trauma
• Often associated with:
• Polytrauma
• Rib fractures
• Spinal injuries

 Mechanism of Injury

1. Direct blow

• Flank impact (RTA, assault)
• Compression against vertebrae

2. Deceleration injury

• Sudden stop → renal pedicle stretch → vascular injury

3. Crush injury

• Between ribs & spine

 Pathophysiology

• Highly vascular organ → bleeding is key issue
• Injury types:
• Parenchymal laceration
• Collecting system disruption
• Renal vascular injury (artery/vein)
• Complications:
• Hemorrhagic shock
• Urinary extravasation → urinoma
• Secondary infection

AAST Renal Injury Grading

Grades I–III = Low grade
Grades IV–V = High grade

 Clinical Features

 Classic triad 

• Flank pain
• Hematuria
• Flank mass

Hematuria:

• Most common sign
• Types:
• Microscopic
• Gross hematuria → more severe injury

 Important:

• No hematuria ≠ no injury
  (especially in vascular pedicle injury)

 Initial Assessment (ATLS Approach)

Primary Survey:

• Airway, Breathing, Circulation
• Control hemorrhage

Secondary Survey:

• Flank bruising (Grey Turner-like)
• Rib fractures (11th–12th rib)

 Investigations 

1. CECT Abdomen (Gold Standard)

• Investigation of choice in stable patients
• Provides:
• Injury grade
• Urinary extravasation
• Vascular injury

Indications for CT:

• Gross hematuria
• Microscopic hematuria + shock
• Suspected high-energy trauma

2. FAST / EFAST

• FAST ultrasound
• Detects free fluid but: Poor for renal injury grading

3. Urinalysis

• RBC count
• Helps triage imaging need

4. IVP (rare, old)

• Used intraoperatively if CT unavailable

 Management

1. Initial Resuscitation

• IV fluids
• Blood transfusion (massive transfusion protocol if needed)
• Monitor:
• Hb
• Urine output
• Lactate

 2. Non-Operative Management (NOM) – STANDARD OF CARE

 Preferred in >90% cases

Indications:

• Hemodynamically stable
• No ongoing bleeding

Includes:

• Bed rest
• Serial Hb monitoring
• Vitals monitoring
• Repeat imaging if needed

 3. Interventional Radiology

 Angioembolization

• Indicated in:
• Active contrast extravasation
• Ongoing bleeding but stable
• Kidney-sparing approach

 4. Surgical Management

Absolute Indications:

• Hemodynamic instability despite resuscitation
• Expanding/pulsatile hematoma
• Renal pedicle avulsion

Procedures:

• Renorrhaphy
• Partial nephrectomy
• Total nephrectomy (last resort)

Management According to Grade

Complications

Early:

• Hemorrhage
• Urinoma

Late:

• Hypertension
• Chronic kidney disease
• Infection / abscess

 Special Situations 

 Pediatric renal trauma

• More prone due to less fat protection
• More conservative approach

 Solitary kidney

• Aggressive kidney preservation
• Avoid nephrectomy

 Anticoagulated patients

• Higher bleeding risk
• Early imaging + monitoring