RENAL TRAUMA
20yrs Male, Assaulted , stab injury came to ER at 6:00pm, B.P - 80/43 mmHg , Spo2. 67% , RR - 43, P.R- 147. FAST Scan - Left Kidney mid cortical lacerated injury, peri renal hematoma. In ABG , sev. metabolic acidosis, Hb-4.3%. Planned for nephrectomy, on OT table - B.p 47/23 with triple inotrope support, Intraop - Huge retroperitoneal hematoma, bowel and other solid organs normal. What would be the next best possible step ? What would be the Prognosis if we proceed with Nephrectomy with this vitals ? as it is a MLC case What would be the possible legal implications on surgeons if patient died on table ( explained prior On table death possibility ) ?.
Considering severe anaemia, hypotension on triple inotropic support, severe metabolic acidosis lacerated renal injury , a large retroperitoneal haematoma. May be patient is going in DIC .- there are every chances of patient dying on operation table As it is a MLC case - I think it is really a tense situation for operating surgeon. It should be clearly told to the attendants there are remote chances of patient surviving even after nephrectomy and a very high risk consent with death on operation table should be doubly signed by close attendants . It is really a heroic work to operate under these circumstances and if patient survives surgery - post operatively patient should be shifted to ICU
Considering severe anaemia, hypotension on triple inotropic support, severe metabolic acidosis lacerated renal injury , a large retroperitoneal haematoma. May be patient is going in DIC .- there are every chances of patient dying on operation table As it is a MLC case - I think it is really a tense situation for operating surgeon. It should be clearly told to the attendants there are remote chances of patient surviving even after nephrectomy and a very high risk consent with death on operation table should be doubly signed by close attendants . It is really a heroic work to operate under these circumstances and if patient survives surgery - post operatively patient should be shifted to ICU
Your only and reasonably reliable guide is the CT and the 3D reconstruction. A single laceration of the.corrtex of the kidney will not give rise to haemodynamic instability of this degree.If contrast was used ,you might know details of the vascular injury. In this case you have to assume major vascular injury or spleen or liver injury depending on the side. Preoperative resuscitation is vital. Of the push comes to the shove cross clamp the aorta as high as you can and explore the retroperitoneal haematoma. I am sure you will findajor vessel damage. If the rentals vessels are involved you have to do a nephrectomy. If not with adequate blood reserve you can repair the vessels.
It may be a case of for damage control surgery First goal is to achieve hemostasis, stop contamination and come out Treat coagulation abnormality, severe anemia, achieve hemodynamic stability, correct electrolyte and metabolic acidosis Second definitive surgery planned at 48 hours Surgeon has done best effort in a very difficult circumstances, where chances of mortality are very high, therefore surgeons are protected by law.
Prognosis is poor. Even doctor should try to balance electrolyte and the worst part is Metabolic acidosis and blood loss. Every possibility must be explained on recordi g and to get consent before proceeding . As there is. O chance or possibility of charging Negligence at no point of prosecution Doctor can be framed and booked for culpable homicide U/S 304.. But..yes case can take a fatal turn at any point of time.
Case of assault See for severe anemia transfused with packed blood cell and stop active bleeding Manage metabolic acidosis and manage bp with inotrop support See special care on inotrop that too lead to bleeding because 3 inotrop ongoing Manage electrolyte imbalance After all stopping bleeding then go for nephrectomy Explain the poor progression to patient relative and take consent on table death
Is the anemia a result of the injury or preexisting.? The cortical tear of the kidney can cause some perirenal haematoma but not this degree of anemia.The huge retroperitoneal haematoma can indicate major vessel damage and be ready to tackle that.Unless there are numerous cortical tearsamd shattered kidney or kidney with major renal vessel injury there is no indication for nephrectomy. If the patient had a prior CT Scan, a 3D reconstruction can easily clear the air about thhe kidney status. Presence of 2 kidneys in every patient should not be a license for removing one without adequate grounds.
Pt is having lt kidney cortical injury with perirenal and retroperitoneal haematoma with instability of vitals where nephrectomy only the option to save the life of the patient . First if all to stabilize the vitals mainly to stop bleeding renal artery embolisation may to tried to minimize the bleeding or stop the bleeding and correction of metabolic acidosis and correction of electrolytes imbalance. If the bleeding can be minimised or stopped by embolisation and stability of vitals achieved then can be planned for nephrectomy inspite of all odd .
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