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