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EMERGENCY CASE REPORTS

Friday , December 17th 2010


SURGERY DEPARTMENT

EMERGENCY ROOM
WAHIDIN SUDIROHUSODO
GENERAL HOSPITAL
MAKASSAR
Friday, December 17th 2010

Ambulation : 3 Patient

Hospitalized : 4 patients

Observation : - patient
Operated : 2 patient
Death : - patient

Total : 7 patients
No. 6
Name : 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 : He wanted to leave the boat and walked on bond
injury 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 : Hematuri
Examination : 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 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 (+) normally
P : Tympani
P : Tenderness (+) at left lumbal region
Secondary Survey

Costovertebral Region :
I : Bruise (-), alignment was good , edema(-)
, hematoma(-),
P : Tenderness (-), tumor mass (-) ren
ballotement is not palpated
P : Tapping pain (-)
Suprapubic Region
I : 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 (-)
Scrotum
I : 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 smooth
Ampoule filled with feces
Prostate is not palpated

Hand scone
Blood (-), slime (-), feces (+)
Laboratory Result
WBC : 15,5 x 103 / L

RBC : 4,84 x 106 / L

HGB : 14,6 g/dL

HCT : 42,4%

PLT : 287x103/ L

CT / BT : 700 / 300

Blood Sugar : 135 mg/dl

Ureum : 21 mg/dl

Creatinin : 0,9 mg/dl

GOT / GPT : 16/ 15 /L


Laboratory Result
Urinalysis
Color : red
pH : 6,0
BJ : 1,015
Protein : 150 mg/dl (+++)
Blood : 250/ L (++++)
Leukosit : 100/L (++)
leukosit sediments : negative
Eritrosit sediments : 8-10
Cell epithelia sediments : 3-5
others sediments : -
USG Abdomen
WORKING : Gross hematuri due to left renal rupture 3rd Grade
DIAGNOSIS 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 Does not request


immediate exploration
(no imaging assessment) (imaging assessment Hemodynamically stable?
performed)

Yes No
Surgical staging with
urologist present to asses
and reapir any renal injury
Intervention
necessary
Mechanism and grade of renal injury?

Blunt Penetrating Renal Exploration Embolization

Limited Extensive
Observe injury Injury

Practical algorithm in the acute treatment of renal trauma


(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.17)
Suspected Blunt Renal Injury
Determine Hemodynamic Stability

Stable Unstable - Any hematuria

Child <50 RBC/hpf Gross Hematuria On Table IVP


Adult Microhematuria SBP Child >50 RBC/hpf
>90 mmHg Adult Microhematuria SBP >90 mmHg
High index suspicious for renal injury
Observe Abnormal IVP
Contrast enhanced spiral CT-scan Normal IVP
UA in 3 weeks Expanding/pulsatile
With 10 minute delayed cuts hematoma
Observe

Grade 1 and 2 Grade 3 and 4 Grade 4 vascular & Grade 5


laceration Renal pedicle trauma
Shattered/destroyed kidney
Observe

No intraperitoneal injuries Renal exploration


Intraperitoneal injuries
Requiring exploration Reconstruction or
Observe bedrest Nephrectomy
Serial HCT

Selective reimaging
Angiography+embolization?
Ureteral Stenting?

Management algorithm for blunt renal trauma


(Genitourinary Trauma; Urology Clinic of North America, Elsevier Saunders 2006: p.23)