Kidney damage may be closed (subcutaneous) and open, isolated or combined with damage to other organs.
Closed renal injury occur more frequently due to injury as a result of direct effects (impact) on the lumbar region, with a sharp turn due to the trunk and shake the body when falling from a height.
With closed kidney damage possible ruptures of kidney parenchyma and renal vessels, renal capsule and vascular renal capsule, crushing the kidney and even separation from her kidney legs. The signs of kidney damage are: pain in the lumbar region, blood in the urine and swelling and increasing pain in the lumbar region because of flow of blood and urine to retroperitoneal fat and education urogematomy. The intensity of hematuria and lumbar hematoma growth are not a measure of the degree of damage to the kidneys. The main sign of serious kidney damage is the deterioration of the patient's blood pressure drop, the clinic of internal bleeding.
Examination of suspected Closed damage Kidney must necessarily include intravenous urography, which allows you to identify the function of the kidney intact and the extent of damage.
In most cases, kidney damage treated conservatively: peace, rest, transfusion of hemostatic blood units, hemostatic and antibiotics to prevent the development of retroperitoneal phlegmon. During treatment repeat x-ray and urine.
In cases where the damage after kidney patient's condition progressively deteriorated, falling blood pressure, decreased hemoglobin content in the blood, the patient should operate — perform the audit lumbotomy kidney. With extensive damage to kidneys produce its removal — nephrectomy.
Open kidney damage (Injuries) are more common during the war, there are gunshot, stab, stab. Open signs of kidney damage are: the selection of blood and urine samples from the lumbar wound and hematuria. Treatment of open injuries kidney is mandatory operation — lumbotomy with revision kidney. During the operation, trying to preserve the kidney, nephrectomy is carried out in a pinch.
Kidney damage divided by subcutaneous (closed) and open. The latter can be a prick, stab and gunshot, isolated or combined with damage to other organs.
Subcutaneous damage often with renal transport, sports and work injuries. Occur much more frequently in women and children than women. Right kidney often left damaged.
Closed kidney damage occurs as a result of direct trauma lumbar (lower back kick in, compression buffer trains, falling sideways on a hard surface), and because of the indirect effects (shaking of the body falling from a height, a sharp contraction of the muscle while trying to keep his balance or hold slump subject). This could cause damage on impact and P. opposite lumbar region. In wartime damage subcutaneous P. occur most because of impact shockwave.
With direct trauma injury can be applied bone fragments XI and XII of the ribs or transverse processes of the vertebrae, the primary importance is the hydrodynamic effect in tightly covered by a fibrous capsule, P., whereby a sharp contraction of its leads to breaks in the parenchyma and fibrous capsule. Breakdown of acute kidney of bed can occur due to a sharp convergence of lumbar muscles and ribs, protective muscle contractions caused by an injury. Acute impairment of renal blood flow, mainly venous, accompanied by rupture of the small and large blood vessels. It is also possible breakaway short legs and kidney gap spanned ureter (in ureteropelvic junction).
Subcutaneous damage P. divided into five major groups. 1. Bursting adipose and fibrous capsule formation and subcapsular hematoma pararenalnoy (Fig. 28). 2. Penetrative breaks forth, which do not reach the calyx or pelvis, extends radially transverse direction, accompanied by small breaks and the formation of the fibrous capsule and subcapsular hematoma pararenalnoy (Fig. 29). 3. Penetrating renal ruptures to form deep cracks in the parenchyma, which amount to cups or pelvis, include damage to blood vessels and the formation of large-diameter large pararenalnyh urogematom (Fig. 30). 4. Crushing of kidney — the deep breaks parenchyma margin pole P.
In the extensive bruising and blood imbibirovannoy adipose tissue is more free-hanging or on vessels of pieces P. In these cases, there is always a vast urogematoma in the retroperitoneal space (Fig. 31). 5. The most severe damage — separation of the kidneys from kidney and the ureter legs — mostly accompanied by damage to the liver, spleen, etc., as well as fractures of the spine and pelvis (Fig. 32).
Leading clinical sign of damage to the private IP is haematuria (see). Hematuria may be transient with mild concussion GP or by tearing the ureter.
In the first hour after injury expressed mild pain: Patients report difficulty breathing and pain on the same side. Then localized pain in the lumbar region, extending along the ureter, palpation of the lumbar region is sharply painful. Observed pain like colic, caused by the passage of the ureter blood clots. The abdominal wall and lumbar muscles on the side of damage stretched. Can identify the symptoms of peritoneal irritation due to formation of a retroperitoneal hematoma. With an increase in its palpable bulging infiltration in the lumbar region, which can be seen and at the examination. Retroperitoneal hematoma, pushing inwards peritoneum gives zone deadened sound in the sides of the abdomen, the zone does not move when you turn the patient's body.
In subcutaneous kidney damage required radiological and urological examination. On plain film lumbar region revealed concomitant fractures, scoliosis with the convexity in a healthy way through a reflex contraction of lumbar muscles, effacement contours P. and psoas muscle on the side of injury.
After removing the patient from shock and stabilize blood pressure of 100/50 mm Hg. Art. or above to produce an intravenous urography, which detects the presence and functional status of the second IP and gives the image compression in the renal pelvis or PA system damage streaks of contrast material in pararenalnuyu urogematomu. There is no trace of contrast material in the cavities P. is not a criterion of injury, since it may be due to vasospasm damaged P.
To refine by damage can be done cystochromoscopy (see), which allows you to see the discharge of blood from the mouth of the ureter and to determine the functional state of the intact P. Most produce retrograde pyelography — either immediately after the injury, P., and 2-3 days after. Retrograde pyelography reveals the extent of damage, P., availability and value urogematomy and dynamic recovery process.
The severity of damage is determined by the intensity and duration of internal bleeding, which is judged not by the degree of hematuria or lumbar hematoma size, and as a patient. Continued despite transfusion, drop in blood pressure, reduced hemoglobin degradation
general state forced to resort to online help — lumbotomy and revision of the kidneys.
Treatment. The most common operation is a nephrectomy because of extensive bruising imbibirovannoy blood tissue is difficult to determine the extent of damage to the kidneys, but it should be possible to strive for conserving surgery: resection of the pole, the repair of pelvic discontinuity, etc. In these cases, the operation is completed and the drainage of the pelvis perinephric space.
Most of the patients with closed injuries P. successfully treated a conservative method, which consists of bed rest for 2-3 weeks, mandatory appointment of hemostatic agents (blood transfusions, vikasola and calcium chloride), and prolonged use of antibiotics: penicillin, 100 000 Unit 8 times a day, streptomycin 500 000 Unit 2 times a day, or broad-spectrum antibiotics.
During treatment for the control of urine and blood make in 2-3 days, X-ray study (intravenous urography or retrograde pyelography) 2-3.
The most severe complications of closed injury P.: education urogematomy infected, septic meltdown clots in blood vessels P. and secondary bleeding. In these cases an urgent nephrectomy. If there is no bleeding, infected hematoma should be widely drained. Conservative treatment can be a long time fever, depending on the resorption of the hematoma.
The prognosis of kidney damage closed favorable. Among the consequences of post-traumatic litiaz should be noted, arising from damage to the mucous membrane of the renal pelvis or inlays of blood clots, and education as a result of post-traumatic hydronephrosis significant scarring in the tissue and post-traumatic paraureteralnoy nephritis, which develops due to impaired circulation in the parenchyma P. and hypoxia it.
Open injuries (Injuries) kidneys are most frequently observed during the war, among them prevail fire (shrapnel and bullet). The main signs of damage to the open spaces is hematuria with clots, urine and blood from the wound.
When kidney damage shown lumbotomy and revision P. With these injuries must also strive to sparing surgery using nephrectomy in extreme cases. It is mandatory that the wide drainage pararenalnoy tissue, prevents urinary infiltration and burrowing pus. Open injuries require immediate P. and persistent use of antibiotics.
The most dangerous complication is anuria due to wound both or only P. P. and reflex anuria requiring intensive antishock measures and control of renal insufficiency, including peritoneal dialysis and hemodialysis.
Among the consequences of renal injury in the first place is the formation of strictures and scar deformity of ureter with subsequent development of hydronephrosis.
It is also possible damage during catheterization P. ureter. They arise in cases of ureteral catheter with stylet and very deep (more than 25 cm), it is administered. Sign penetration catheter into the parenchyma P. is the selection of blood on it, tight flow of contrast medium into the catheter. On retrograde pyelogram contrast agent is distributed under the capsule, clearly delineates the contour of the kidney or perforation of the fibrous capsule appears as a formless contrasting spots in the projection P.
Immediately remove the catheter, to appoint a patient antibiotics and hemostatic agents. Such injuries are rare exceptions prevent complications.