RGU Trauma Flashcards
Trauma death
- Leading cause of death b/w the ages of 1-44
Most commonly injured organ in the urogenital system?
- Kidney
- Renal injuries occur in 10% of abdominal traumas
- MOI classified as blunt or penetrating
Renal trauma main causes
- Blunt trauma (80-90%)
*secondary to MVS’s, contact sports, falls and assaults
- Penetrating trauma (10-20%)
*secondary to stab or gunshot wounds
Renal trauma diagnosis
- Penetrating obvious w/ wounds
- Blunt trauma may reveal flank ecchymosis
- Urinalysis may show microscopic or gross hematuria
*most importan test as result determine who needs to be imaged
*degree of hematuria may not predict severity of trauma and may actually be absent in 5% of traumas
Hematura post trauma
- Usually 1st indicator of renal injury
- Dipstick hematuria correlates w/ 5-10 RBC’s/HPF
- Should be catherized specimen or first voided specimen
Renal trauma imaging indications
- In adults- all penetrating and blunt trauma assoc. w/ gross hematuria or microscopic hematuria w/ shock (<90 SBP) requires imaging for staging
- In peds (<16) any hematuria requires imaging
- CT has replaced Intravenous Pyelogram (IVP) as the gold standard
Renal trauma grading
- Grade 1: the renal capsule has not been violated; parenchymal injury w/ blood staying under the capsule (subcapsular hematoma)
- Grade 2: capsule violation; parenephris (blood outside the kidney)
- Grade 3: thru the corticomedullary junction
- Grade 4: injury involves collecting system or ureter or renal artery thrombosis as a result (sheared artery)
- Grade 5: shattered kidney; multiple deep lacerations or more important a peducle injury
***up to grades 3-4 we just observe, may not have to do anything; grades 4-5 may need kidney operation w/ 5 need kidney removal usually
Cortical rim sign
- Pathognomonic radiographic sign of renal artery thrombosis
*parenchyma of kidney not getting blood flow but capsule is
Renal trauma management
- Most renal injuries secondary to bunt trauma is non-operative
- Only 7% require exploration
- When properly staged w/ CT scan, all grade 1-3 and most grade 4 can be managed conservatively
*if no CT scan have to operate to observe
- Bed rest, serial hematocrits, and follow-up imaging
Indications for renal trauma operation
- Absolute:
*expanding or pulsatile hematoma
- Relative:
*extravasation
*non-viable tissue
*arterial injury
*incomplete staging
Renal trauma surgery precautions
- Must determine if there is in fact a 2nd kidney
*palpation is unreliable
- Use single-shot IVP
*2 cc/kg, IV push
*single film taken 10min post-injection
- Renal exploration if abnormal or equivocal
Renal trauma step-wise treatment
- Diagnose
- Stage
- Active and attentive observation
- Selective surgery
- Renal reconstruction and salvage
Bladder trauma
- 2nd most common urogenital organ injured
- Bladder and/or urethral injuries are present in 15% of all pelvic fractures
- 85% of traumatic bldder ruptures are found to be assoc. w/ pelvic fractures
Bladder trauma diagnosis
- Most important test is a urinalysis
- Almost 100% of bladder injuries have hematuria, 98% have gross hematuria
- Radiographic eval
*cystography is the definitive study for diagnosis
- Cystography
*350cc water soluble contrast via gravity drainage thru a foley catheter
*full film
*DRAINAGE FILM- will miss 15% of injuries if neglected
CT cystography
- Definitive diagnosis test for bladder trauma
- Must provocatively fill bladder w/ 300-400cc water soluble contrast
- Cannot rely on passive bladder filling during contrast CT scan
Bladder ruptures
- Related to degree of bladder filling at time of injury
- Extraperitoneal: 65% empty bladder
- Intraperitoneal: 25% full bladder
- Combined: 10%- unlucky, mortality rate from other assoc. injuries 60%
- Intraperitoneal injuries more common in pediatrics (70% of all injuries)
Bladder trauma treatment
- Minor injuries: foley catheter until hematuria resolves (3-5 days)
- Extraperitoneal ruptures: foley catheter for 7-10days, repeat cystogram prior to removal of catheter UNLESS OPERATING FOR SOMETHING ELSE
- Intraperitoneal ruptures: operative exploration and repair
- All penetrating injuries require operative repair
Bladder trauma operative management
- Midline incision
- Trans-peritoneal repair
- Midline cystotomy
- Avoid hematoma manipulation
- Transvesical repair- open the bladder
- Assess UO’s and intramural ureters
- Cystostomy tube
Urethral trauma
- Classically due to pelvic fracture
- Urethra divided into anterior and posterior segments, landmark is the external urethral sphincter
- Anterior injuries: penetrating and straddle injuries
- Posterior injuries: distraction injuries
Urethral trauma diagnosis
- History- straddle injury, penetrating, pelvic fractue
- Blood at the meatus (tip of penis) present in 75% of anterior urethral injuries
- Hematuria
- Inability to void
- Perineal hematoma
- Inability to pass catheter
- High-riding prostate
Straddle injuries management
- Injury from falling on something hard right on the perineum area
- Manage initially w/ suprapubic tube
- Fix via perineal exploration 3-6 months post injury- allow assoc. injuries to heal
- Many present in a delayed fashion; 6 monthns to 2yrs post trauma; you can fix these when you find them
Posterior urethral injuries
- Present in 5% of all pelvic fractures but pelvic fracture present in 98% of all disruptions
- Higher incidence in anterior ring fractures and b/l rami fractures
- Pt at significant risk for bleeding; off to angio often times where we are asked to do a retrograde urethrogram (RUG)
Urethral trauma management
- Never pass a foley catheter w/ blood at the urethral meatus
- If catheter does not pass easily, even w/ no blood at the metus, don’t pass the catheter
- Obtain a retrograde urethrogram
*20-30cc water soluble contrast
*12F foley
Testicular rupture surgical treatment
- Operative management within 72hrs of injury
- Midline scrotal incision
- Expose
- Debride exposed tubules
- Testicular salvage for improved self image, maintenance of hormonal function
