KIDNEY TRAUMA

Mohamad kevin Yoga Bobby pratama saputra Michelle regina sudjadi Fika triani Michael jonathan Pembimbing : dr. Antonius Sp.B, FINACS

IDENTITAS PASIEN
Name Age Sex Address ADM No Check in Check out

: sartuk tardi : 43th : male : Rt 4 Rw 3 Widara, Mekarsari Maleber : 153416 : 05/10/2013 : 11/10/2013

ANAMNESIS Keluhan utama tidak bisa BAK Riwayat : 10 hari yang lalu, pasien jatuh dari pohon, jatuh pada posisi miring ke kanan, kemudian pasien dirawat di RS wijaya, selama dirawat pasien tidak bisa BAK kemudian di pasang selang, setelah dipasang px tetap ridak bisa BAK (tidak keluar), warna air seni kemerahan tampak gumpalan darah, selama dirawat pasien merasa tidak ada perubahan , kemuadian pulang.

PHYSICAL EXAMINATIONS
KU : sakit sedang Kesadaran : CM GCS : E4 M5 V6

TANDA VITAL
5/10/13 6/10/13 7/10/13 8/10/13 9/10/13 10/10/1 3 11/10/1 1

TD

100/90

110/80

120/80

110/80

110/80

120/80

110/80

N S R

80 36.0 20

86 36.0 18

96 38.0 20

90 37,9 19

94 37,6 20

90 37.5 18

88 37.0 20

PHYSICAL EXAMINATION

Head : normal, injury () Eyes : conjunctiva anemia +/+,pupilary isocor , RC +/+, 3mm THT : Rhinorea (-), Othorea (-), Bleeding () Neck : Injury (-)

Thorax : BP/ simetris, injury (-) Abdomen : flat, soepel, peristatic normal, injury (-), distention suprapubic (+) pain presure (-), Blast full () Ekstremitas : akral hangat, crt < 2, oedem -/-

X-RAY IMAGING
Tidak tampak fraktur costa Jantung tidak membesar Tidak tampak tb paru aktif

USG 5/10/2013
Gambaran laserasi ren dextra Hidronefrosis berat dengan hidroureter dupleks e.c obstruksi ureter distal Blood cloth VU

USG 8/10/13

Gambaran hematome disertai hidronefrosis berat dan hidroureter sinistra e.c obstruksi ureter distal

TERAPI
5/10/13 Ketorola c 3x1amp 6/10/13 = 7/10/13 8/10/13 9/10/13 10/10/13 11/10/13 -

Toramin
Kalnex Amoxan Nonemi Urinter Renax

3x1amp 3x1tab 3x1tab -

= = = -

3x1amp
= = = 2x1tab -

=
= = = = 3x1tab

=
= = =

=
= = =

=
= = =

lanfix
Kalnex tab

2x1tab
-

=
3x1tab

=
=

=
=

CONT
Diit : lunak Mobilisasi : bed rest

Vesica urinaria washing > NaCl 0,9% 1x/hr

ANATOMI GINJAL

Papilla renis --- calyx minor --- calyx major ---pelvis renisureter --- vesica urinaria --urethra.(termasuk tractus urinarius)

PATHOPHYSIOLOGY

IMAGING FOR UNINARY TRACT

USG ( Ultrasonografi). Foto polos . IVP. angiography APG/RPG. Isotope scanning .( Ked.Nuklir ). CT Scan . MRI.

USG : ULTRASONOGRAFI.

Gel.suara frek: 3,5 -10 Mhz.

Mengetahui Letak,ukuran,kelainan. Membedakan solid dengan kistik. Gerakan organ ,jantung /janin. Guiding biopsi atau punksi. Dll.

TERMINOLOGY :
Unechoic/echofree. Isoechoic dengan .. Hiperechoic. Acustic shadowing.

Posterior. Lateral.

ULTRASONOGRAFI GINJAL:
Ukuran ginjal ( 10-11cm x 4 x 5 cm). Parenkim ( korteks dan sinus). Sinus Ginjal ( central pelvokaliceal complex) Kelainan kelainan ginjal. Obstruksi.

USG GINJAL NORMAL.

USG KANDUNG KEMIH NORMAL.

HIDRONEPHROSIS

URETEROLITIASIS DISTAL .

INTRA VENOUS PIELOGRAFI.( IVP)

Persiapan : Pemeriksaan Ureum/kreatinin. Pengosongan Usus dari fecal residu dan udara.

INTRA VENOUS PYELOGRAFI.

Persiapan IVP. 1. Maksud : membersihkan usus kecil dan kolon --tidak menutupi kontur ginjal/kon tras dalam traktus urinarius. 2.Cara: hari I makan makanan yg tidak banyak ampas. hari II. 3 tablet dulcolax jam 14.00. 3 22.00.puasa. 1 supp jam 5 pagi. Cairan dibatasi dalam 24 jam terakhir. Jangan banyak bicara. VU dikosongkan seb.pem.

PELAKSANAAN PEM. IVP.:

Kontras

non ionik. Dosis 300 mg/Kg BB.

BNO.
Test

alergis. Foto 3-5 menit. ( Stuwing ) Foto 10-15 menit( Stuwing ). Foto 20-30 menit tanpa stuwing. Full blast. Post voiding.

IVP

PADA

PEMERIKSAAN

IVP.

Pembesaran ginjal diffus atau focal. Fase nephrogram dan ekskresi berkurang. Kompressi atau Pendesakan pelvo kalises.

INTRODUCTION

Injuries to the genitourinary system occur in 2% to 5% of adult trauma patients, usually in the setting of blunt trauma. Although rarely life threatening, they often are associated with more serious injuries and require prompt and thorough management.

ETIOLOGY

The mechanism of injury should alert the clinician to the possibility of renal trauma. The following list is not all-inclusive, but it highlights the major mechanisms that generate renal injuries: Penetrating (eg, gunshot wounds, stab wounds) Blunt - Rapid deceleration (eg, motor vehicle crash, fall from heights); direct blow to the flank (eg, pedestrian struck, sports injury)

CONT

Iatrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy, renal biopsy, percutaneous renal procedures) Intraoperative Other (eg, renal transplant rejection, childbirth [may cause spontaneous renal lacerations]

CONT
Grade 1 Grade 2

CONT
Grade 3

Grade 4

#Almost same like grade 2

MECHANISM AND DIAGNOSIS

approximately 80% of renal injuries are the result of blunt trauma and 20% penetrating trauma. Renal injury should be suspected and evaluated in patients with hematuria, or a mechanism of injury or physical findings conducive to renal trauma Significant renal injury can exist in the absence of hematuriaspecifically, major injuries to the renal pedicle or transection of the ureteropelvic junction (UPJ). Staging of renal trauma is done either by CT or intraoperative findings.

TREATMENT
Nonoperative management is the standard of care for hemodynamically stable patients with grade I to III and nonvascular grade IV renal injuries. Operative exploration is indicated in unstable patients and those with renal hilar or pedicle injuries (vascular grade IV and V).

CONT

If the patient is explored for other reasons, prior to appropriate imaging evaluation, the retroperitoneum should be examined for evidence of expanding or pulsatile hematomas, the presence of which should prompt renal exploration. A one-shot IVP can be performed prior to renal exploration to document function of the contralateral side should nephrectomy become necessary. The treatment of nonpulsatile, nonexpanding retroperitoneal hematomas found at the time of exploratory laparotomy is controversial. Generally, if such injuries are the result of blunt trauma, they may be safely watched. Stable retroperitoneal hematomas resulting from penetrating trauma should be explored. Again, evidence of contralateral renal function should be documented.

CONT
Early vascular control of the injured renal unit maximizes chances of renal unit salvage. This is best accomplished through a midline transperitoneal approach. Incision of the mesentery just medial and inferior to the inferior mesenteric vein allows exposure of the right- and left-sided renal vessels (Fig. 30-3). Nephrectomy should be entertained when renal injuries are considered unre-constructable or when patients are clinically unstable from other injuries.

CONT

In stable patients with nonhilar vascular injuries or parenchymal injuries, renal reconstruction is frequently successful and should be considered. Principles include debridement of devascularized tissues, careful closure of collecting system injuries, and reinforcement of the site of repair with omentum or perinephric fat.

COMPLICATIONS

Prolonged urine extravasation may be seen following renal reconstruction. Such drainage typically resolves spontaneously. Ureteric stent placement may be required to facilitate antegrade drainage. Urinoma formation can occur days to weeks after repair. Retroperitoneal uri-nomas or perinephric abscesses may be treated with percutaneous drainage. Postinjury hypertension can occur in up to 5% of patients following renal trauma and may occur up to 6 months after injury. This occasionally resolves spontaneously, but antihypertensive treatment is frequently required. Nephrectomy is the most common treatment if hypertension cannot be controlled.

PROGNOSIS
Quo ad vitam : Dubia ad bonam Quo ad funtionam : Dubia Quo ad sanationam : Dubia

Tergantung dari staging trauma ginjal & terdapat komplikasi penyulit dari penyakitnya.

THANK YOU