AUAGL Trauma (2020)

Question 1

Imaging for trauma patient with gross or microscopic hematuria and SBP <90?

Difference between adults and children?

Answer 1

CT with contrast (get immediate and delayed images; don’t need non-con)

Children often will not exhibit hypotension (where an adult would).

Question 2

Does a stable trauma patient with MoI or PE finding need imaging?

Answer 2

Yes. Get CT w/ contrast (immediate and delayed).

Rapid deceleration, significant blow to flank, rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank, or lower chest

Question 3

Preferred imaging in suspected renal trauma?

Answer 3

CT + IV contrast

Need immediate + delayed images. Don’t need non-con phase for trauma.

Question 4

Preferred management strategy for stable renal trauma patients?

Answer 4

If no s/s shock and stable serial hgb then preferred strategy is noninvasive management.

Noninvasive management includes close hemodynamic monitoring, bed rest, ICU admission and blood transfusion.

Avoids unnecessary nephrectomy and preserves renal function.

Question 5

In hemodynamically UNSTABLE patients not responding to resuscitation, what do you do next?

Answer 5

IMMEDIATE INTERVENTION

OR exploration or angioembolization by IR

Question 6

Imaging findings that direct you intervene immediately (thus prior to resuscitation attempts)

Answer 6

Large perirenal hematoima (>4 cm)

Vascular contrast extravasation in the setting of deep or complex renal laceration (AAST grade 3-5)

Immediate intervention means either open exploration or IR embolization

Question 7

Stable patient with renal parenchymal injury + urinary extravasation– what may you do?

Answer 7

You can initially observe the stable patient with renal injury

Excluded from this would be patient with renal pelvis or proximal ureteral injuries.

Question 8

Imaging findings suggestive of renal pelvis or proximal ureteral injury?

Answer 8

1. Large medial urinoma

2. Contrast extravasation on delayed images without distal ureteral contrast

Question 9

Who needs follow up imaging with renal trauma?

Answer 9

You need to reimage 48 hours later.

1. Deep renal laceration (AAST grade 4-5)
2. Clinical signs of complications (fever, ongoing blood loss, abd distension, worsening flank pain)

Uncomplicated, low grade (AAST 1-3) do not routinely need repeat imaging.

Question 10

When do you need to perform urinary drainage for renal trauma?

Answer 10

In the presence of complications such as enlarging urinoma, fever, increasing pain, ileus, fistula, infection.

Can use ureteral stent, PCN, or perc drain (into the urinoma)… or a combo or 2 or all 3!

Question 11

Absolute indications for open exploration in context of renal trauma?

Answer 11

Expanding/pulsatile hematoma, hemodynamic instability, suspected renal pedicle avulsion, and UPJ disruption

Use transabdominal approach, rather than flank.

Question 12

What do you do for a STABLE trauma patient with suspected ureteral injury?

Answer 12

CT A/P with contrast and delayed images (10-minutes) (don’t need non-contrast)

Question 13

Suspected ureteral injury in trauma patient who went directly to OR for laparotomy without imaging?

Answer 13

Urologist should directly inspect the ureter

If findings equivocal can do retrograde pyelogram or inject methylene blue.

Question 14

MUST, SHOULD, MAY ???

Surgeons ______ repair traumatic ureteral lacerations at the time of laparotomy in stable patients.

Answer 14

SHOULD

Question 15

Managing ureteral injury in the UNSTABLE patient during laparotomy?

Answer 15

Options:

Tie off the ureter, PCN for urinary drainage, delayed repair.

Externalized ureteral stent tied off at the level of proximal ureteral defect.

Question 16

How to manage ureteral contusion identified at time of laparotomy?

Answer 16

Attempt ureteral stent placement

Also in select cases can do resection of contused/injured ureteral segment and primary repair (UU)

Question 17

Ureteral injury and stent placement is either unsuccessful or impossible?

Answer 17

Next step is PCN (duh)

Question 18

Management of ureterovaginal fistula?

Answer 18

Initially attempt management with ureteral stent. If fails then surgical management (usually ureteral reimplantation, but all of the techniques possibly apply here depending on exact injury).

Question 19

Management of ureteral injury proximal to iliac vessels?

Answer 19

Should perform primary repair (spatulated, tension free repair over a stent).

Question 20

Management of ureteral injury distal to iliac vessels?

Answer 20

Manage with primary repair (UU) or ureteral reimplantation.

Primary repair only if segments seem healthy. If concern for ureteral viability, resect and just do reimplant.

Autotransplantation or bowel segment interposition are never the answer in the acute setting. If injury is this bad then tie off ureter proximally, get PCN, and delayed repair.

Question 21

Management of endoscopic ureteral injuries?

Answer 21

Ureteral stent or PCN, as able.

If urinary diversion fails, then use surgical repair technique depending on the location/severity of the ureteral injury.

Question 22

What to do in stable patient with gross hematuria and pelvic fracture?

Answer 22

MUST perform cystogram (either plain or CT is acceptable)

Aim for 300ml bladder volume for max fill.

Question 23

In addition to GH + pelvic fx, what other scenario warrants cystogram?

Answer 23

GH + mechanism of injury that is concerning

Other clinical signs of bladder injury can warrant imaging (inability to void, elevated BUN and Cr, abd distension, low UOP, SP pain)

Question 24

Management of intraperitoneal bladder injuries?

Answer 24

MUST perform surgical repair for intraperitoneal injuries in the context of both blunt and penetrating external trauma.

Question 24

Management of intraperitoneal bladder injuries?

Answer 24

MUST perform surgical repair for intraperitoneal injuries in the context of both blunt and penetrating external trauma.

Question 24

Management of intraperitoneal bladder injuries?

Answer 24

MUST perform surgical repair for intraperitoneal injuries in the context of both blunt and penetrating external trauma.

Question 25

Management of extraperitoneal bladder injuries?

Answer 25

Uncomplicated: should perform catheter drainage

Complicated: surgical repair of injury

What constitutes complicated extraperitoneal injuries:

• Exposed bone spicules int he bladder lumen
• Concurrent rectal or vaginal lacerations
• Bladder neck injury
• If ORIF is happening then fix the bladder injury

SHOULD get follow up cystogram to confirm that the complex, extraperitoneal bladder injury has healed.

Question 26

Do you need a suprapubic tube in additional to urethral catheter after bladder injury repair?

Answer 26

NO. Studies show no additional benefit to SPT + urethral catheter.

Can consider SPT if tenuous repair with lots of hematuria, immobilized due to severe neuro or ortho injuries.

Question 27

Pelvic trauma + blood at urethral meatus? What do you need to do?

Answer 27

SHOULD perform RUG

How to do a RUG:

A retrograde urethrogram is performed by positioning the patient obliquely with the bottom leg flexed at the knee and the top leg kept straight. If severe pelvic or spine fractures are present, leaving the patient supine and placing the penis on stretch to acquire the image is appropriate. A 12Fr Foley catheter or catheter tipped syringe is introduced into the fossa navicularis, the penis is placed on gentle traction and 20 mL undiluted water soluble contrast material is injected with the image acquired.

Question 28

What should the initial management of most PFUI be?

Answer 28

Percutaneous or open SPT placement in most cases is the first step.

Important to remember that trauma patients need urinary drainage to monitor resuscitation efforts.

Question 29

Surgeons _________ place suprapubic tubes (SPTs) in patients undergoing open reduction internal fixation (ORIF) for pelvic fracture.

Answer 29

MAY

No evidence exists to indicate that SPT insertion increases the risk of orthopedic hardware infection. Thus, considerations of the urethral injury and its management should dictate the use of SPT. Particular circumstances, such as gross fecal contamination or open fractures, may suggest exceptions to these general observations.

Question 30

What do the guidelines say about primary endoscopic realignment of PFUI?

Answer 30

Urologist MAY attempt primary endoscopic realignment. However, the attempt should not be prolonged –> lots of fluid going in, delays other care, etc.

Only doing this in hemodynamically stable patients!

Question 31

Follow up after traumatic urethral injury? What are you looking for?

Answer 31

Monitor for 1 year

Stricture, erectile dysfunction, urinary incontinence

Question 32

Management of uncomplicated penetrating trauma of the anterior urethra?

Answer 32

SHOULD perform prompt surgical repair in patients with uncomplicated penetrating trauma of the anterior urethra.

Primary repair should not be undertaken if the patient is unstable, the surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or loss.

Question 33

Management of straddle injury to the anterior urethra?

Answer 33

SHOULD establish prompt urinary drainage.

Immediate operative intervention to repair or debride the injured urethra is contraindicated due to the indistinct nature of the injury border.