A 35-year-old woman is brought to the trauma bay after a fall from a height of 15 feet. She is hemodynamically stable with blood pressure 128/78 mmHg and heart rate 92 bpm. Physical examination reveals right flank tenderness and mild abdominal distension. FAST is negative for free fluid. Urinalysis shows gross hematuria (>50 RBCs/hpf). CT scan of the abdomen and pelvis with IV contrast reveals a right-sided renal laceration with contained perinephric hematoma and no active extravasation. There is no evidence of collecting system disruption. What is the most appropriate management?

Explanation

## Clinical Assessment This patient has a **grade III renal laceration** (contained perinephric hematoma without active extravasation or collecting system injury) and is **hemodynamically stable**. These factors strongly favor **nonoperative management (NOM)**. ## Renal Injury Grading & Management | Grade | Injury Type | Hemodynamic Status | Management | |-------|-------------|-------------------|-------------| | I–II | Contusion, minor laceration | Stable | Observation + imaging | | III | Laceration with contained hematoma | **Stable** | **NOM: bed rest, serial exams** | | III | Laceration with contained hematoma | **Unstable** | Angioembolization or surgery | | IV | Laceration extending into collecting system | Any | Angioembolization ± stent | | V | Shattered kidney or pedicle injury | Any | **Nephrectomy** | ## Key Point: **Hemodynamically stable patients with grade III–IV renal injuries are managed nonoperatively in >95% of cases.** Nephrectomy is reserved for grade V injuries or hemodynamic instability refractory to resuscitation. ## Management Algorithm for Renal Trauma ```mermaid flowchart TD A[Renal Injury on CT]:::outcome --> B{Hemodynamically Stable?}:::decision B -->|No| C{Grade V or active extravasation?}:::decision C -->|Yes| D[Nephrectomy]:::action C -->|No| E[Angioembolization]:::action B -->|Yes| F{Grade I-III with contained hematoma?}:::decision F -->|Yes| G[Nonoperative Management]:::action F -->|No| H{Grade IV or V?}:::decision H -->|Yes| I[Angioembolization ± stent]:::action G --> J[Bed rest, serial exams, repeat imaging 48-72 hrs]:::action ``` ## Why Nonoperative Management Here? 1. **Hemodynamically stable** (BP 128/78, HR 92) — no ongoing hemorrhage 2. **Contained hematoma** — no active extravasation on CT 3. **Collecting system intact** — no urine leak 4. **Grade III injury** — standard indication for NOM 5. **Gross hematuria resolves** within 2–4 weeks in most cases ## Clinical Pearl: **The "unstable renal injury" triad requiring intervention:** - Hemodynamic instability despite resuscitation - Active extravasation on CT - Shattered kidney (grade V) → **Angioembolization (if collecting system intact) or nephrectomy (if grade V).** ## High-Yield: - **>95% of blunt renal injuries are managed nonoperatively** [cite:ATLS 10th Edition Ch 8] - Nephrectomy is rarely needed in the acute setting; it is reserved for **grade V injuries** or **hemodynamic instability unresponsive to resuscitation** - Angioembolization is the **preferred intervention** for hemodynamically unstable patients with grade III–IV injuries (preserves renal function) - **Prophylactic antibiotics** are NOT routinely indicated for uncomplicated renal injuries ## Follow-up Protocol - Bed rest until hematuria resolves - Serial abdominal examinations to detect peritonitis or deterioration - Repeat imaging (ultrasound or CT) in 48–72 hours to confirm stability - Imaging again at 6 weeks to assess healing - Return precautions: fever, flank pain, hemodynamic changes → urgent re-evaluation