What is the next step in managing a patient with mild right flank tenderness and hematuria after a motor vehicle collision with a negative Focused Assessment with Sonography for Trauma (FAST) exam and unremarkable chest and pelvic X-rays?

From the Guidelines

The next step in managing a patient with mild right flank tenderness and hematuria after a motor vehicle collision with a negative FAST exam and unremarkable chest and pelvic X-rays is to obtain a contrast-enhanced CT scan of the abdomen and pelvis. This recommendation is based on the most recent and highest quality study available, which emphasizes the importance of diagnostic imaging with intravenous contrast-enhanced computed tomography (CT) in stable blunt trauma patients with microscopic hematuria and mechanism of injury or physical exam findings concerning for renal injury 1. The patient's presentation with mild right flank tenderness and hematuria following a motor vehicle collision raises concern for potential renal injury, and a contrast-enhanced CT scan is essential to evaluate the renal parenchyma, collecting system, and vascular structures, allowing for grading of any renal injury if present. Some key points to consider in the management of this patient include:

• The negative FAST exam is reassuring for the absence of significant free fluid in the abdomen, but it cannot reliably detect solid organ injuries, particularly those of the kidney.
• The CT scan will provide detailed information about the renal parenchyma, collecting system, and vascular structures, allowing for grading of any renal injury if present.
• Additionally, the CT will evaluate other abdominal organs that may have been injured but not detected on the initial screening tests.
• While awaiting the CT scan, the patient should receive appropriate intravenous fluid resuscitation, typically with isotonic crystalloids such as normal saline or lactated Ringer's solution, and pain management as needed with medications like acetaminophen or, if necessary, opioids such as morphine 2-4 mg IV or hydromorphone 0.5-1 mg IV.
• Vital signs should be monitored closely for signs of hemodynamic instability that might indicate ongoing bleeding, as non-operative management (NOM) is the treatment of choice for all hemodynamically stable or stabilized minor, moderate, and severe lesions 1. The use of contrast-enhanced CT scan with delayed images is the gold standard to select patients for NOM, and it allows for accurate classification of the degree of injury and associated injuries 1. In general, follow-up imaging is not required for minor renal injuries managed non-operatively, but it may be necessary for moderate and severe injuries, depending on the patient's clinical condition 1. Overall, the management of this patient should prioritize the evaluation and treatment of potential renal injury, while also considering the patient's overall clinical condition and the potential for other associated injuries.

From the Research

Patient Assessment and Next Steps

The patient presents with mild right flank tenderness and hematuria after a motor vehicle collision, with a negative Focused Assessment with Sonography for Trauma (FAST) exam and unremarkable chest and pelvic X-rays. Given these findings, the next step in management should focus on further evaluating the renal injury.

Imaging Modalities for Renal Trauma

• Contrast-enhanced computed tomography (CT) is the imaging modality of choice in the evaluation and management of renal trauma, as it can quickly and accurately depict renal injuries and associated injuries to other abdominal or retroperitoneal organs 2.
• CT can help detect active hemorrhage and urinary extravasation, guiding transcatheter embolization and delineating preexisting disease entities that may predispose kidneys to posttraumatic hemorrhage 2, 3.
• While ultrasound imaging may be useful in evaluating renal trauma, particularly in pediatric patients, its sensitivity and specificity may vary, and it may not detect all clinically significant renal injuries 4.

Considerations for Patient Management

• The presence of hematuria, even microscopic, warrants further evaluation with imaging studies, such as CT, to rule out significant renal injury 2, 4.
• Renal artery pseudoaneurysm is a rare complication after renal injury and should be suspected in cases of recurrent hematuria after renal trauma, with selective angiographic embolization being an effective treatment option 5.

Next Steps

• Given the patient's presentation and the negative FAST exam, a contrast-enhanced CT scan of the abdomen and pelvis should be considered to further evaluate the renal injury and rule out other associated injuries 2, 6.
• The patient's hematuria, although microscopic, warrants careful monitoring and consideration of further imaging or urologic consultation if the hematuria persists or worsens 4, 5.