Page 1647 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

1166 PART 10: The Surgical Patient

Injuries to the gallbladder should be treated by cholecystectomy these injuries are repaired by débridement, primary repair, and stent-
unless the patient’s hemodynamic status is precarious, when a cholecys- ing. Although in the past traumatic hematuria of any degree has been
tostomy may be performed as a temporizing measure. investigated with IV pyelography, a more selective approach is now
■ RETROPERITONEAL HEMORRHAGE recommended. This change in approach has resulted from the low yield
of IV pyelography in all patients with trauma; also, in the presence of
Frequently, hemorrhage in the retroperitoneal space is identified at hematuria, the yield in terms of positive lesions identified varies from
15% to 60%. Most of the injuries discovered (65%-70%) are considered
laparotomy. This problem can be very difficult to treat, and when pos-
sible, preoperative investigation including x-ray of the pelvis, CT scan, minor, involving a parenchymal laceration or contusion that does not
require surgical intervention. Major parenchymal laceration through the
or angiography will allow consideration of specific diagnostic possibili-
ties and a more directed surgical approach. When the patient is taken corticomedullary junction and often into the collecting system usually
causes gross hematuria and represents 10% to 15% of renal injuries.
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to the OR prior to any of these investigations because of instability,
however, a decision needs to be made regarding proper treatment of the The remainder of renal injuries is associated with a shattered kidney or
renal pedicle injury. These considerations, together with the cost of the
retroperitoneal hemorrhage.
Division of the retroperitoneum into three zones may be used to procedure, as well as the incidence of allergic reaction (5.7%), including
guide therapeutic decisions (zone 1, central; zone 2, lateral; zone 3, anaphylaxis, renal failure, and death (0.0074%), have led to a change in
pelvic). In general, hemorrhage that is associated with a major pelvic the approach to hematuria in the assessment of genitourinary trauma.
In most instances, the major cause of death from genitourinary trauma
fracture and confined to the pelvis or originating in the pelvis should
be treated without exploration unless either there is a penetrating is the associated injuries, and the investigation using IV pyelography has
had very little effect on management or outcome in general.
injury that is likely to involve the iliac vessels or the hematoma is pul-
Microhematuria without shock has not been shown to be associated
satile. Exploration of such retroperitoneal hematomas usually results in with lesions requiring surgical intervention, whereas gross hematuria or
massive uncontrollable hemorrhage when the source is the pelvic frac-
ture. This type of hemorrhage often is best treated by external fixation microhematuria with shock or a major abdominal injury has been asso-
ciated with lesions requiring surgery in up to 10% of cases. Penetrating
of the fractured pelvis and blood transfusions. Angiography is required
when hemorrhage is continuing with a view to embolizing any iden- renal injuries are associated with lesions requiring surgery both with and
without hematuria. On the basis of these observations, IV pyelography
8
tifiable bleeding artery. The mainstay of initial control of hemorrhage
from pelvic fractures, however, is immediate restriction of movement should not be routine in abdominal trauma. Also, if the patient is having
a CT scan of the abdomen for another reason, or if there is only microhe-
of the fracture fragments, and this is accomplished most expeditiously
by external fixator application. Other devices that provide temporary maturia without shock or any evidence of severe injury, IV pyelography is
not recommended. High-resolution spiral CT where available has virtually
restriction of pelvic volume include application and tightening of a bed
sheet around the pelvis or the use of commercially available external replaced IV pyelography as the imaging technique in investigating genito-
urinary trauma. Imaging is recommended in the following circumstances:
velcro binders. Several centers have reported control of hemorrhage for
pelvic fractures in patients who do not respond to pelvic binding and (1) When there is gross or microhematuria with shock, (2) if there is
hematuria in the presence of a major abdominal injury, or (3) if there is a
fluid infusion, by retroperitoneal packing through an extraperitoneal
anterior approach through an infra umbilical skin incision. penetrating injury and the trajectory suggests the possibility of renal injury,
even without hematuria. The main indication for surgical intervention in
Apart from hematomas arising from the pelvis, hematomas that are
not pulsatile or expanding and that are located in the lateral retroperito- renal trauma is an injury with major hemorrhage such that the patient’s
hemodynamic stability cannot be maintained with rapid transfusion of
neal spaces (zone 2) also should be left unexplored, and further investiga-
tion should be done postoperatively in the form of contrast-enhanced CT crystalloid and blood. Otherwise, most patients with renal trauma are
treated nonoperatively (Fig. 120-7) at first. They should be observed very
scan and angiography as indicated. If the lesion is expanding or pulsatile,
the retroperitoneal space has to be explored to identify the bleeding closely in an ICU setting for any deterioration in hemodynamic status sug-
gesting continued major hemorrhage that requires surgical intervention. If
source and control it. Temporary control of an infradiaphragmatic source
of hemorrhage can be achieved by thoracotomy and clamping of the there is failure to visualize both kidneys with contrast-enhanced CT, angiog-
raphy should be conducted to determine the extent of the injury producing
supradiaphragmatic aorta. However, when the hematoma or bleeding
does not extend to the aortic hiatus, temporary control may be achieved nonfunctioning of the kidneys and to identify a possibly correctable renal
vascular injury such as a traumatic renal artery thrombosis or internal flap.
within the abdomen by compressing the aorta at the diaphragmatic
The main principle in surgical treatment of kidney injury is to con-
crura. This compression can be done by an assistant’s hand, an aortic trol hemorrhage while preserving kidney function; this is best achieved
compressor, or a sponge stick. By incising the peritoneum and mobiliz-
ing and displacing the esophagus, a clamp also may be applied directly to by exploring the kidney only in selected patients in whom there is an
expanding or pulsatile hematoma or when signs of urine extravasation
the aorta to achieve temporary control of intra-abdominal hemorrhage.
A retroperitoneal hematoma that is centrally located (zone 1) in the are present. In order to ensure adequate hemorrhage control, the renal
midabdomen represents possible injury to the pancreas and major retro- vascular pedicle should be isolated first and secured to allow occlusion if
peritoneal vessels. These hematomas require exploration with a view to this becomes necessary. If after attempts at repair or partial nephrectomy
there is still massive bleeding after release of renal pedicle occlusion,
determining the extent of the injury and, in the case of the pancreas, to
determine whether the pancreatic duct has been violated. The lesion is then nephrectomy becomes necessary, especially in the unstable patient
who is known to have a contralateral normal kidney.
then treated as outlined earlier for pancreatic trauma. Surgical exposure
Hematuria also may result from injury to the bladder, and the sus-
strategies are as outlined previously to allow adequate visualization of picion of bladder injury should be investigated by cystography, at least
retroperitoneal structures as well as vascular control. three views being taken with the bladder both filled and emptied to
■ GENITOURINARY INJURIES determine whether or not there is any extravasation of bladder contents.
Retrograde cystography has been reported to be more accurate in diag-
Although hematuria is absent in 5% to 10% of patients with genitouri- nosing bladder injuries than the spiral CT. Extraperitoneal bladder rup-
nary trauma, it still is a most important sign of genitourinary injury. ture may be treated by catheter drainage alone, whereas intraperitoneal
The patient frequently has sustained blunt or penetrating injury to the bladder rupture usually warrants open laparotomy with débridement
flank or diffuse transfer of force to the abdomen. Occasionally, there and formal repair of the laceration.
is a direct penetrating injury into the bladder or kidney. Penetrating Although in most multiply injured patients, urinary catheterization
injury resulting in ureteric lacerations is very rare, and where possible, per urethra is routine for monitoring the urine volume and consistency

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