EMERGENCY CASE REPORTS
Friday , December 17th 2010SURGERY DEPARTMENT
EMERGENCY ROOMWAHIDIN
SUDIROHUSODO GENERAL HOSPITAL
MAKASSAR
EMERGENCY CASE REPORT
WAHIDIN SUDIROHUSODO HOSPITALMAKASSAR
Friday, December 17th 2010
Ambulation : 3 Patient
Hospitalized : 4 patients
Observation : - patient
Operated : 2 patient
Death : - patient
Total : 7 patients
No. 6Name : Mr. syamsul Sex : Male
Age : 23 years old No. Reg : 45 10 86
Chief complaint : Bloody urination
History taking : Suffered since 38 hours before admitted to the hospital due to blunt trauma. There is no history of loss of consciousness and no vomiting
Mechanism of injury
: He wanted to leave the boat and walked on bond between boat and the pier, suddenly there was wave , he loss his balance and fell down with his stomach bumped to boat
Injury sustain : abdomen Symptom & sign : HematuriExamination : Physical examination, laboratory examination, abdominal
USG , abdominal CT
PHYSICAL EXAMINATION
Primary Survey
A: Clear
B: RR : 20 x/minutes, spontaneous, symmetric, thoraco abdominal type
C: BP : 140/90 mmHg, HR : 84 x/minute, regular, adequate
D: GCS 15 (E4M6V5), pupil equal Ø 3 / 3 mm , LR +/+
E: T (ax) : 36,8 oC
Secondary Survey
Abdomen :I : Bruise (-) , excoriated wound (-), color
same with vicinity, edema(-), hematoma(-)
A: Peristaltic (+) normallyP : TympaniP : Tenderness (+) at left lumbal region
Secondary Survey
Costovertebral Region :I : Bruise (-), alignment was good ,
edema(-) , hematoma(-), P : Tenderness (-), tumor mass (-) ren ballotement is not palpatedP : Tapping pain (-)
Suprapubic RegionI : Seen flat, skin color same with its vicinity ,
edema (-), hematoma (-)P: Tenderness (+), tumor mass (-)
Secondary Survey
Genetalia Externa Region:Penis:I : Seen penis circumcised yet, , skin color same with
its vicinity, edema (-),hematoma (-), blood at OUE (-)P : Tenderness (-), tumor mass (-)ScrotumI : Seen skin more dark than vicinity , edema(-), hematoma(-)P : Tenderness (-)Perineum:I : Seen skin more dark than vicinity, edema (-), hematoma (-)P: Tenderness (-), tumor mass (-)
Rectal Touch
Sphincter was tight Mucosa was smoothAmpoule filled with feces Prostate is not palpated
Hand sconeBlood (-), slime (-), feces (+)
Laboratory ResultWBC : 15,5 x 103 / μL
RBC : 4,84 x 106 / μL
HGB : 14,6 g/dL
HCT : 42,4%
PLT : 287x103/ μL
CT / BT : 7‘00” / 3’00”
Blood Sugar : 135 mg/dl
Ureum : 21 mg/dl
Creatinin : 0,9 mg/dl
GOT / GPT : 16/ 15 μ/L
Laboratory ResultUrinalysis
Color : redpH : 6,0BJ : 1,015Protein : 150 mg/dl (+++)Blood : 250/ μL (++++)Leukosit : 100/μL (++) leukosit sediments : negative
Eritrosit sediments : 8-10Cell epithelia sediments : 3-5
others sediments : -
USG Abdomen
WORKING DIAGNOSIS
: Gross hematuri due to left renal rupture 3rd Grade due to blunt trauma
MANAGEMENT : • Medicaments• Report to urologic surgeon advice : conservative
PROGNOSIS : Fair - Good
FOLLOW UP : Vital sign and hematuri
Campbell-Walss Urology: 9th ed. 2007
Handbook of Urology; Diagnosis and Therapy 9th ed. 2007
Grading Renal Trauma (Campbell-Walss Urology: 9th ed. 2007)
Concomitant abdominal or other injuries
Yes No
Request immediate exploration(no imaging assessment)
Surgical staging with urologist present to asses and reapir any renal injury
Does not request immediate exploration(imaging assessment
performed)Hemodynamically stable?
NoYes
Renal Exploration Embolization
Mechanism and grade of renal injury?
Intervention necessary
Blunt Penetrating
ObserveLimited injury
Extensive Injury
Practical algorithm in the acute treatment of renal trauma
(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.17)
Unstable - Any hematuriaStable
Determine Hemodynamic Stability
On Table IVP
Grade 1 and 2 Grade 3 and 4 laceration
Normal IVP Abnormal IVPExpanding/pulsatile
hematoma
Grade 4 vascular & Grade 5 Renal pedicle trauma
Shattered/destroyed kidney
Suspected Blunt Renal Injury
Child <50 RBC/hpfAdult Microhematuria SBP
>90 mmHg
Observe
Observe
Renal explorationReconstruction or
Nephrectomy
No intraperitoneal injuries Intraperitoneal injuriesRequiring exploration
Observe bedrestSerial HCT
Selective reimagingAngiography+embolization?
Ureteral Stenting?
Gross HematuriaChild >50 RBC/hpf
Adult Microhematuria SBP >90 mmHgHigh index suspicious for renal injury
ObserveUA in 3 weeks Contrast enhanced spiral CT-scan
With 10 minute delayed cuts
Management algorithm for blunt renal trauma
(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.23)
Thank you
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