6 Prehospital Care No specific intervention is needed One exception… Penile amputationDirect pressure to stop bleedingWrap amputated penis in sterile dressingPlace in container of ice– not in direct contact with ice
7 History GU tract assessed during secondary survey Mechanism of Injury—blunt vs. penetratingPast medical historyProblems with renal functionHigh risk for renal insufficiency (diabetes, hypertensionUninephricGross hematuriaDifficulty voiding since injury
8 Physical Exam Flank exam Costal margin exam Thoracolumbar spine exam Risk stratifies injury to kidneysTenderness, palpable mass, ecchymosisCostal margin examInjury to kidneys, spleen, and liverThoracolumbar spine examPalpation to identify potential fracturesTransverse spine fracture higher risk of renal injuryBack exam for ecchymosisPelvic stabililityInstability increases risk of bladder injury
9 Physical Exam Rectal exam Perineal exam External genitalia exam May not be useful in all trauma patientsReserved for patients with:Pelvic fracturesEvaluates prostate: high riding/boggy? urethral injuryPenetrating wound to lower abdomenEvaluate rectal tone when spinal cord injury suspectedPerineal examHematoma and edemaSuggests possible urethral injuryExternal genitalia examPenile injury: edema, laceration, deformityUrethral injury: blood at meatusTesticular injury: edema, laceration, deformity
10 Foley Catheter Placement Indications in critical patient:Test for hematuriaMonitor urine outputEase of urinationContraindications Retrograde urethrogramBlood at urethral meatusBoggy/high-riding prostatePerineal hematomaDifficulty catheterization Retrograde urethrogramUrethral injuryUrethral strictureProstatic hypertrophyCancer
11 Urinalysis GU trauma screening test UA for hematuria Urine b-hCG for pregnancy statusGross hematuriaRenal injuries 50%Renal injuries without hematuria 5%Renal artery injuryDisruption of the uteropelvic junctionEvaluate GU tract and other abdominal organsCT scan with delayed images: kidneys +abd organsCystogram: bladder
12 Urinalysis Microscopic hematuria Pediatric population Routinely used but controversialCutoff levels of 5-50 RBC/hpf used for additional abdominal imagingVast majority of GU injuries have >50 RBC/hpfAdult populationControversialCutoff levels of >10 –>25 RBC/hpf used for additional abdominal imaging
13 Urinalysis Microscopic hematuria Adult population Standard based on old studies that attempted to identify renal injury requiring interventionBlunt trauma patient needs upper urinary tract imaging if…Gross hematuriaMicroscopic hematuria and shockThese studies did not take in to account:Renal injuries not requiring interventionAbility of microscopic hematuria to account for non-GU injuriesThe ability of microscopic hematuria to detect lower urinary tract injuriesDegree of hematuria requiring abdominal imaging varies from >10 RBC/hpf to >25 RBC/hpfConsider the whole picture: degree of hematuria, mechanism of action, and additional physical exam findings
14 Additional Labs Complete blood count Type and screen BUN and Creatnine levelsIncrease with:Renal injuryUreter/bladder injuryCT abdomen with contrastX-rayUltrasound
15 Specific Injuries & Treatment Upper urinary tractRenal injuriesLumbar spine fractures (esp. transverse process fractures)Injury grade guides treatmentGrade I-III: non-operative repair in children and adultsGrade IV: half require surgeryGrade V: all require surgeryAcute complicationsHemorrhage, urinoma, hydronephrosis, arterial pseudoaneurysm, infectionLong-term complicationsRenal failure, hypertension
16 Renal Injury Grading System GradeDescriptionIContusion or non-expanding subcapsular hematomaIINon-expanding perirenal haematoma, cortical laceration <1 cm deep without extravasationIIICortical laceration >1 cm without urinary extravasation or collecting duct ruptureIVLaceration through corticomedullary junction into collecting system or renal artery or vein injury with contained hematomaVShattered kidney or renal pedicle avulsion
30 Renal InjuryGrade 3 renal lacerationAbsent right nephrogram
31 Renal Injury Grade 5 injury; shattered right kidney Absent right nephrogram
32 Specific Injuries & Treatment Upper urinary tract (cc)Ureteral injuriesRare, 1% of GU injuriesGunshot wounds 94%Stab wounds 5%Blunt trauma 1%Sudden decelerating forceNo specific physical exam findingsHematuria 75%Screening: CT abdomen with contrast and delay viewsGrading: scale not well acceptedDiagnostic: Retrograde pyelographyTreatment: ureter with active extravasation of urineStenting, primary closure, ureteroneocystostomyUreteroureterostomy less frequentComplications: urinoma, abscess, stricture, hydronephroma, fistula, ileusThese injuries are RARE—1%. So, if the lecture is too long, we should remove this slide or make it much smaller.
33 Specific Injuries & Treatment Lower urinary tractBladder injuriesClassic triad: gross hematuria, suprapubic pain, inability to voidRisk of injury increasedPelvic fractures, pregnant (>1st trimester,) intoxicatedHematuriaGross hematuria in 67%Injury rare when <25 RBC/hpfDiagnosisBladder CT scanPlain film cystogramDelays may show increase in BUN & Creatnine
34 Specific Injuries & Treatment Bladder injuriesInjury classification and treatmentContusion/hematomaTreatment: observe for resolution of hematuriaIntraperitoneal ruptureSudden increase in intra-bladder pressureTreatment: operative repair + urine catheter for 14 days + broad spectrum antibioticsRepeat cystogram looking for urine leakCatheter removed if no leakExtraperitoneal ruptureBony fragment laceration; sheering forceTreatment: observe for 7 days + urine catheterEvaluation for resolution of hematuriaNo hematuria repeat cystogramComplications: infection, urinoma, inability/difficulty voiding, fistulaEmergency department visit post-op with urinary retentionPlace urine catheter after consulting urologistCheck urine for infection
35 Bladder Injury Extraperitoneal rupture Again, maybe to many examples. We can remove some of the examples if the lecture is too long.Extraperitoneal rupture
38 Bladder Injury Intraperitoneal rupture Bowel wall is outlined and contrast is tracking up the left paracolic gutter.
39 Bladder Injury Extraperitoneal rupture Fluid outlining the lateral aspects of the bladder in the retroperitoneal space.
40 Bladder InjuryFluid outlines the bowel wall.Intraperitoneal rupture
41 Specific Injuries & Treatment Urethral injuriesRare; male 95%Risk increased withPelvic fractures: pubic symphysis and sacroiliac diastasis, straddle fracture, Malgaigne fractureStraddle injuriesPenetrating trauma close to urethraPenile fracturePhysical exam:Blood at urethral meatus, perineal hematoma/edema, high riding prostate on rectal—rareGross hematuria—common
42 Specific Injuries & Treatment Urethral injuries (cc)Gross hematuria + difficulty placing catheter => urethral evaluationExtension of urethral laceration, increase bleeding, contamination of hematomaGrading system exists but is not well acceptedInjury severity determined by:Location of the injuryComplete vs incomplete transection of the urethraDiagnosis: Retrograde urethrogramTreatment: if urethra is injured, consult urology
45 Specific Injuries & Treatment External genitalia injuriesPenile lacerationSuperficial penile laceration repair in emergency dept.Complex penile laceration consult urologyCompromised Buck’s fascia consult urologyPenile fractureOccur during coitus or masturbationPresentation: penile pain, loss of erection, deformity, swelling, difficulty voidingTreatment:Involvement of corpus caverosum or Bucks fascia (common) operative interventionSuperficial to Bucks fascia (less common) nonoperative managementThe picture of the fractured penis is funny. But I think you should talk seriously so everyone thinks you think it is real. On the next slide you can say it was a joke. This helps everyone laugh a little.
46 Specific Injuries & Treatment External genitalia injuries (cc)Penile amputationTreatment: reimplantation if warm ischemic time <6 hoursIn emergency department, penis is kept cold (wrapped in dry gauze on ice,) and urology consulted immediatelyPenile foreign bodiesBlunt foreign bodies in the distal urethra removal in the emergency departmentSharp, not easily visualized in the proximal urethraurology consultation for operative interventionComplication: strictures, impotence, incontinence
47 Specific Injuries & Treatment Testicular injuriesUncommon; blunt trauma 85%Testicular rupture: most serious injuryHematocele: hemorrhage in to the tunica vaginalisTesticular dislocation: rare; manual reduction in the emergency department recommendedDiagnosis: Ultrasound study of choiceTreatmentNonoperative intervention for minor injuriesScrotal elevation, ice, non-steroidal antiinflammatory drugs, limited activityOperative interventionTesticular ruptureExpanding hematoceleInability to reduce testicular dislocationScrotal deglovingTesticular salvage as low as 40%Complications: bleeding, abscess, skin necrosis, infertility, testicular atrophy, testicular necrosis
48 Testicular Injury Injured or uninjured? Top right picture: left testicle OK (smooth contour), right testicle injured (irregular contour and edema.) Bottom left picture: doppler ultrasound to evaluate blood flow to the testicles– Left testicle OK (blood flow seen in the testicle), right testicle has no blood flow, no color in the testicle. Depending on the time, you can present the slides and ask with testicle they think is OK and which one they think is injured. You can also ask them explain their choice. If you don’t have time, simply tell them what they are looking at.Injured or uninjured?
49 Summary Kidneys are the 3rd most commonly injured abdominal organ Specific GU track injury is evaluated during the secondary surveyMost renal injuries are minor with no long term complicationsGross hematuria OR microhematuria + shock = GU traumaRenovascular injuries require prompt diagnosis and urological consultationPelvic fracture + >25 RBC/hpf => consider bladder injuryBlood at urethral meatus, perineal hematoma, high-riding prostate => consider urethral injuryImaging selection:Renal CT abdomen with delayed images; one-shot IVP; ultrasonographyUreteral one-shot IVPBladder plain film cystogram; CT cystogramUrethral retrograde urethrogramTesticular ultrasound