Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
I. Trauma Information
Mechanism of Injury: (Blunt trauma – motor vehicle accident, fall from height, etc. / Penetrating trauma – gunshot wound, stab wound)
Time of Injury:
II. Subjective
Symptoms:
Abdominal pain (location, severity, radiation)
Gross hematuria (blood in urine)
Flank pain
Nausea, vomiting
Decreased urine output
III. Objective
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
General: Appearance of illness, signs of shock (tachycardia, hypotension)
Abdominal: Tenderness, guarding, flank mass (if present)
Guilin Flank Sign (unilateral flank pain with ipsilateral costovertebral angle tenderness) – suggestive of kidney injury
Laboratory:
Complete blood count (CBC) with differential (looking for anemia)
Serum electrolytes (potassium, sodium)
Blood urea nitrogen (BUN) and creatinine
Urinalysis (microscopic hematuria may be present even if gross hematuria is not reported)
Coagulation studies (PT, PTT) – may be abnormal in severe trauma
IV. Imaging
Urinalysis with microscopy: To confirm presence and type of hematuria.
Abdominal and/or Pelvic CT scan with contrast: Preferred imaging modality for diagnosing kidney trauma, assesses for degree of injury, bleeding, and potential complications.
Abdominal X-ray (if CT scan not readily available): May show signs of hematuria or displaced kidney.
Retrograde pyelography (RPG) or renal angiography (rarely used now): May be used in specific situations if CT scan is contraindicated.
V. Assessment
Grade of Kidney Trauma (American Association for the Surgery of Trauma (AAST)) classification:
Grade I: Microscopic hematuria only, minimal injury
Grade II: Minor laceration, small subcapsular hematoma
Grade III: Laceration involving less than 50% of thickness, moderate hematoma
Grade IV: Laceration involving 50% or more of thickness, large hematoma
Grade V: Shattered kidney, devitalized tissue
Hemodynamic status: Stable, hypotensive (suggestive of significant bleeding)
Presence of urinary extravasation: Leakage of urine from the kidney
VI. Plan
Management: Depends on the grade of injury and hemodynamic stability.
Conservative management: (Grade I-III, stable patient) with serial monitoring of vital signs, labs, and urinalysis.
Intervention:
Embolization: Minimally invasive procedure to block bleeding vessels for Grade III-IV injuries.
Nephrectomy: Surgical removal of the kidney for Grade IV-V injuries or uncontrolled bleeding.
Surgery to repair the laceration: May be attempted for select Grade III-IV injuries.
Blood transfusion: If needed to correct anemia or blood loss.
Pain management: Medications to manage abdominal pain.
Antibiotics: Prophylactic antibiotics may be used to prevent infection, especially if there is urinary extravasation.
Urology consult: Consider consultation with a urologist for definitive management decisions, especially for Grade III or higher injuries.
Follow-up:
Serial monitoring of vital signs, labs, and urinalysis to assess for improvement or complications.
Imaging follow-up with CT scan may be needed to monitor healing or assess for complications.
Schedule next appointment in [interval] based on clinical course.