THE GENERAL METHOD FOR A KIDNEY INJURY

This extends Section 51.3 on the care of a severely injured patient. If the patient also has a severe abdominal injury, this takes precedence over his injured kidney. Treat him conservatively and only operate on the indications listed in the next section (67.2).

THE CONSERVATIVE TREATMENT OF KIDNEY INJURIES

RESUSCITATION Transfuse the patient as necessary.

OBSERVATION Record his pulse every 15 minutes initially, and less often later. Examine his abdomen often for a gradually increasing loin mass.

X–RAYS An intravenous pyelogram is useful, so take one. The only contraindication to it is a low blood pressure which will allow insufficient excretion to give you a useful film. Do a pyelogram as soon as you can, without waiting for haematuria to stop, and before gas in the patient’s gut has had time to obscure the films. Give him a double dose of contrast medium, but otherwise take the pyelogram exactly as usual, except that you should not compress his abdomen. Take a control film, followed by films at 5 minutes and 15 minutes; take another film at 30 minutes if you do not see the normal kidney well at 5 and 15 minutes.

Look for: (1) A functioning kidney on the other side, (2) delayed or absent function on the injured side, and (3) blood clots in the calyces. A normal pyelogram does not necessarily mean a normal kidney. You may also see fractures of the transverse processes of the lumbar vertebrae, which are often associated with kidney injuries, and obliteration of the psoas shadow.

URINE Save a sample of all the urine the patient passes, so that you can compare succeeding specimens. if his injured kidney is healing, his urine will change from red to brown. If it becomes red again, further bleeding has started.

FLUIDS AND GASTRIC ASPIRATION Adequate fluid and electrolytes will help him to pass clots without too much pain. Paralytic ileus is a risk in severe cases and may complicate the administration of fluid (10.14).

If there is no indication for an operation, and no distension which might indicate ileus, give him plenty of fluids by mouth.

If you have to operate, or there are signs of Ileus, pass a nasogastric tube and aspirate it repeatedly, as long as there is any fluid to aspirate. Give him fluid intravenously.

Keep him quiet in bed for at least a week until all bleeding has stopped, and his pyelogram shows no gross abnormality. If necessary, sedate him thoroughly. Observe him for 3 weeks if necessary.