Genitourinary Trauma

1. Genitourinary Trauma Fran�ois Dufresne McGill Emergency Medicine February 13th 2002

2. The Case of Jeremy 23 y.o male Driver, Seatbelted Frontal Impact, High Speed (? 100Km/h) Airbag + Other driver dead Car completely destroyed Empty EtOH bottles in the OTHER car Patient was conscious at the scene. On scene: BP=85/50 HR:120 RR:22 Sat:98% - Ugences-Sant� brings you Jeremy with this story�- Ugences-Sant� brings you Jeremy with this story�

3. Jeremy� A: Clear. C-spine protection. Backboard+ B: A/E symetric. O2 Sat N. No crepitus. Trachea central. C: BP:100/60 HR:100 Mentating well. D: GCS=15 PERL. Pt is exposed. O2 - iv � monitor Temperature N Capillary Glucose N

4. Jeremy AMPLE C/O abdo. Pain + �hip� pain C/O right lower leg pain Secondary Survey Spleen normal. Mild suprapubic tenderness. Pelvic instability Probable right tibial # No gross blood at meatus. Rectal Normal. �Doctor, can I put a Foley?�

5. Jeremy What are your concerns? Foley? What will be the usefulness of dipstick? Dipstick good enough? U/A? What if he has microscopic hematuria? What if he has a pelvic fracture? Any different if you had blood at meatus? Urethrogram? Cystogram? Abdominal CT? Worried about the kidneys? Bladder? Does the low BP changes your suspicion for a GU injury? - So those are all questions that, I hope, you�ll be able to answer at the end of the presentation.- So those are all questions that, I hope, you�ll be able to answer at the end of the presentation.

6. Introduction GU Trauma overlooked 10-20% of all injured patients Long term morbidity Impotence Incontinence Life-threatening injuries first GU trauma, because of its very often non life-threatening injuries and its subtle presentation, is very often overlooked and poorly recognized in the emergency departement. However, approximateley 10-20% of all injured patients have some kind of GU involvement which can lead to very debilitating long term sequalae such as incontinence and impotence. Although the more life-threatening injuries of the primary survey must be addressed first, we must be alert to the clues pointing to the presence of GU injuries. So in the OVERALL management of all trauma patients, it is very important that we have a complete understanding of GU injuries, how to deal with it and how it can impact on patient outcome. Being good at managing trauma patients doesn�t only mean being good at putting chest tubes. GU trauma, because of its very often non life-threatening injuries and its subtle presentation, is very often overlooked and poorly recognized in the emergency departement. However, approximateley 10-20% of all injured patients have some kind of GU involvement which can lead to very debilitating long term sequalae such as incontinence and impotence. Although the more life-threatening injuries of the primary survey must be addressed first, we must be alert to the clues pointing to the presence of GU injuries. So in the OVERALL management of all trauma patients, it is very important that we have a complete understanding of GU injuries, how to deal with it and how it can impact on patient outcome. Being good at managing trauma patients doesn�t only mean being good at putting chest tubes.

7. Plan Urethral Injury Bladder Injury Hematuria in Trauma Kidney Injury - So I�m going to talk about the different method of investigations, the evidence behind it and the management of the different injuries. - Hematuria: I�m going to review the evidence behind what we do or should do. - I will not talk about uretheral because it is rare and usually from penetrating injuries (and I want to focus on blunt trauma). I will not talk also about external genitalia injuries because this is probably a talk in itself, obvious on exam and usually left to the urologist.- So I�m going to talk about the different method of investigations, the evidence behind it and the management of the different injuries. - Hematuria: I�m going to review the evidence behind what we do or should do. - I will not talk about uretheral because it is rare and usually from penetrating injuries (and I want to focus on blunt trauma). I will not talk also about external genitalia injuries because this is probably a talk in itself, obvious on exam and usually left to the urologist.

8. Definitions Upper tract Kidney Ureters Lower tract Bladder Urethra External genitalia for purposes of investigation and staging of urologic injuries, GU traum is divided into� Each category is futher subdivided on the basis of a blunt or penetrating mechanism of injury. I�m going to focus on BLUNT trauma during my talk.for purposes of investigation and staging of urologic injuries, GU traum is divided into� Each category is futher subdivided on the basis of a blunt or penetrating mechanism of injury. I�m going to focus on BLUNT trauma during my talk.

9. Urethral Trauma Almost exclusively in male Significant morbidity Stricture Incontinence Impotence If unrecognized: Converting partial to complete tear Inaccurate assessment of U/O Foley catheter implication Female: severe pelvic fracture and bony displacement along with lacerations through the bladder neck and vagina are present in cases of urethral trauma. Morbidity: 15% (stress) incontinence in this study by Andrich: Men from 19-51! In previous studies, depending on the method used to repair the urethra, the rate of Incontinence/impotence is up to 70%, needing RE-operation to correct the problem. Journal of Urology, 1996 Oct.: Stricture:49-97%. Impotence:0-36%. Incontinence: 0-21%. (Impotence and incontinence is a complication of procedures with less strictures. �and as you learned in your ATLS, Foley catheter is C.-I. if you suspect urethral trauma.Female: severe pelvic fracture and bony displacement along with lacerations through the bladder neck and vagina are present in cases of urethral trauma. Morbidity: 15% (stress) incontinence in this study by Andrich: Men from 19-51! In previous studies, depending on the method used to repair the urethra, the rate of Incontinence/impotence is up to 70%, needing RE-operation to correct the problem. Journal of Urology, 1996 Oct.: Stricture:49-97%. Impotence:0-36%. Incontinence: 0-21%. (Impotence and incontinence is a complication of procedures with less strictures. �and as you learned in your ATLS, Foley catheter is C.-I. if you suspect urethral trauma.

10. Anatomy Male urethra divided into four segments: Protatic urethra urogenital diaphragm: Membranous urethra Bulbous urethra Pendulous urethraMale urethra divided into four segments: Protatic urethra urogenital diaphragm: Membranous urethra Bulbous urethra Pendulous urethra

11. important anatomical features: - urogenial diaphragm attaches to bones of pelvis - prostate attaches to symphysis pubis by puboprostatic ligaments. Important to differentiate anterior VS posterior because injuries are caused by different mechanisms, involve different symptoms and are treated differently. important anatomical features: - urogenial diaphragm attaches to bones of pelvis - prostate attaches to symphysis pubis by puboprostatic ligaments. Important to differentiate anterior VS posterior because injuries are caused by different mechanisms, involve different symptoms and are treated differently.

12. Posterior Urethra Violent external force Pelvic # in ? 90% Pelvic # : 5-25% of Posterior urethral injury Pelvic # in 80-95% Pelvic # in 80-95%

13. Clinical Features Gross hematuria in 98% Inability to void Blood at urethral meatus Pelvic / suprapubic tenderness Penile / scrotal / perineal hematoma Boggy / high-riding prostate/ ill-defined mass on rectal examination. inability to void�actually you tell them not to do so ! Physical findings can be minimal because the bladder neck remains competent. �=urethral injury until proven otherwise : NO FOLEYinability to void�actually you tell them not to do so ! Physical findings can be minimal because the bladder neck remains competent. �=urethral injury until proven otherwise : NO FOLEY

14. Digital Rectal Exam in Trauma Porter et al. Am Surg, 2001. Prospective Level II Trauma Center. 423 patients. DRE on all. 7 (1.7%) pelvic fracture. NO Urethral injury Prostate exam didn�t change management This study that was looked at in one of the Journal Watch� But�patients less sick (level II), less GU injuries/pelvic fracture� So if you here in the future people quoting this study to argue about the uselessness of the rectal exam, keep in mind that these patients were not the sickest ones.This study that was looked at in one of the Journal Watch� But�patients less sick (level II), less GU injuries/pelvic fracture� So if you here in the future people quoting this study to argue about the uselessness of the rectal exam, keep in mind that these patients were not the sickest ones.

15. Posterior Urethral rupture - so the rationale behind the findings on rectal exam�- so the rationale behind the findings on rectal exam�

16. Diagnosis:Retrograde Urethrogram Pretest KUB film Supine position Injection of 25ml of water-soluble contrast Different techniques X-ray when 10ml left and after 25ml Post-voiding x-ray. KUB to identify pelvic fracture, bony displacement, foreign objects. Christmas tree adapter on the end of a 60cc syringe.KUB to identify pelvic fracture, bony displacement, foreign objects. Christmas tree adapter on the end of a 60cc syringe.

17. Retrograde Urethrogram

18. Retrograde Urethrogram:Interpretation Contrast extravasation + Contrast in bladder Contrast extravasation only -limits: spasm of urether can limit extravasation or passage in bladder. TYPE I: Stretching/Elongation of urethra TYPE II: Partial or complete rupture of prostatomembranous urethra: extravasation above urogenital diaphragm (pelvis) TYPE III: Partial or complete rupture of prostatomembranous urethra + rupture of urogenital diaphragm and bulbous urethra: extravasation in pelvis AND perineum. (2X as common and more severe). TYPE IV: Bladder neck involved TYPE V: ONLY anterior urethra.-limits: spasm of urether can limit extravasation or passage in bladder. TYPE I: Stretching/Elongation of urethra TYPE II: Partial or complete rupture of prostatomembranous urethra: extravasation above urogenital diaphragm (pelvis) TYPE III: Partial or complete rupture of prostatomembranous urethra + rupture of urogenital diaphragm and bulbous urethra: extravasation in pelvis AND perineum. (2X as common and more severe). TYPE IV: Bladder neck involved TYPE V: ONLY anterior urethra.

19. Partial Tear

20. Complete Tear

21. Management Partial tear careful passage of 12-14 Fr. Foley. If any resistance: Urology Complete tear: Urology + suprapubic cath. If Foley already there and suspect tear: LEAVE FOLEY IN PLACE Small tube alongside the foley Angiocath 16-gauge Modified urethrogram

22. Management�by Urology Controversial Complete VS Partial Posterior VS Anterior Foley X 3-14 days Suprapubic catheters Surgical approach / Endoscopy Delayed repair usually - I don�t want to get into the details because this is obviously not our field anymore�- I don�t want to get into the details because this is obviously not our field anymore�

23. Foley Catheter NO if you suspect a urethral injury Most of urethral injuries: Pelvic # or Gross hematuria Initial bladder effluent MUST be looked at. Danger to convert partial into complete Successful passage ? complete tear NEVER REMOVE A FOLEY WHEN YOU SUSPECT A PARTIAL TEAR AFTERWARDS. ANY colored urine other that yellow again, if you have any of the physical findings mentionned earlier, you MUST suspect a urethral injury and you CAN�T put a foley until you have proved that the urethra is intact. ..=blood�of course, severe rhabdomyolysis can produce large amount of myoglobin, there�s hemoglobinuria, food/Rx� again, if you have any of the physical findings mentionned earlier, you MUST suspect a urethral injury and you CAN�T put a foley until you have proved that the urethra is intact. ..=blood�of course, severe rhabdomyolysis can produce large amount of myoglobin, there�s hemoglobinuria, food/Rx�

24. important anatomical features: - urogenial diaphragm attaches to bones of pelvis - prostate attaches to symphysis pubis by puboprostatic ligaments. Important to differentiate anterior VS posterior because injuries are caused by different mechanisms, involve different symptoms and are treated differently. important anatomical features: - urogenial diaphragm attaches to bones of pelvis - prostate attaches to symphysis pubis by puboprostatic ligaments. Important to differentiate anterior VS posterior because injuries are caused by different mechanisms, involve different symptoms and are treated differently.

25. Anterior Urethra More common than posterior Direct trauma Usually NO pelvic # Blood at meatus Unable to micturate Penile/Scrotal/Perineal Contusion Hematoma Fluid collection - bulbous injury is the most common urethral injury - direct trauma so history is very suggestive (fall astride a bicycle, post, etc.)- bulbous injury is the most common urethral injury - direct trauma so history is very suggestive (fall astride a bicycle, post, etc.)

26. Sleeve Hematoma Penile injury confined by Buck�s fascia. Corporal rupture during intercourse. Scrotum normal. SLEEVE hematoma.Penile injury confined by Buck�s fascia. Corporal rupture during intercourse. Scrotum normal. SLEEVE hematoma.

30. Butterfly Hematoma Anterior urethral rupture through Buck�s fascia confined by Colles� fascia. Anterior urethral rupture through Buck�s fascia confined by Colles� fascia.

31. Anterior Urethral Rupture - Urine filling penis and scrotum and extending into abdomen beneath Scarpa�s fascia. No extension into thigh.- Urine filling penis and scrotum and extending into abdomen beneath Scarpa�s fascia. No extension into thigh.

32. Testicular hematoma (right testicle) in the dromedary. This is usually caused by testicular trauma due to fighting with other males I think that from now on I will not say: �As equiped as a horse� but: �as equiped as a dromedary� !!! Testicular hematoma (right testicle) in the dromedary. This is usually caused by testicular trauma due to fighting with other males I think that from now on I will not say: �As equiped as a horse� but: �as equiped as a dromedary� !!!

33. Anterior Urethra:Management NO Foley if injury suspected Retrograde Urethrogram Urology: Surgical Treatment - very similar to posterior injury for an Emerg point of view.- very similar to posterior injury for an Emerg point of view.

34. Bladder Trauma Adult: Extraperitoneal organ Bladder dome = weakest point Blunt: 60-85% MVA: #1 cause Important to recognize Pelvic/abdominal wall abscess/necrosis Peritonitis Intra-abdominal abscess Sepsis / Death Peds: Intraperitoneal until 6 y.o Better protection in adult b/c it is in the pelvis. In peds, it is higher. Bladder dome���this is were the peritoneum is adjacent to the bladder� Peds: Intraperitoneal until 6 y.o Better protection in adult b/c it is in the pelvis. In peds, it is higher. Bladder dome���this is were the peritoneum is adjacent to the bladder�

35. - There is a close relationship between the dome of the bladder and the peritoneal cavitiy.- There is a close relationship between the dome of the bladder and the peritoneal cavitiy.

36. Types of rupture Extraperitoneal Most common Pelvic # in 89-100% Bladder rupture in 5-10% of all pelvic # Intraperitoneal Extravasation of urine in abdomen Sudden force to full bladder Associated injuries +++ Mortality (20%) pelvic #�thought to be a spicule of bone. Also: tear at ligamentous attachement / force of blunt trauma Extraperitoneal: urine collects in perivesicular space Increased intraluminal pressure and rupture at the WEAKEST point of bladder. Associated injuries not more frequent but more severe (40% of cases). Combined: 10% with mortality up to 60% pelvic #�thought to be a spicule of bone. Also: tear at ligamentous attachement / force of blunt trauma Extraperitoneal: urine collects in perivesicular space Increased intraluminal pressure and rupture at the WEAKEST point of bladder. Associated injuries not more frequent but more severe (40% of cases). Combined: 10% with mortality up to 60%

37. Clinical Presentation 98% : Gross hematuria 2%: Microscopic hematuria + Pelvic # 100%: Gross hematuria 85% Pelvic # Hx and P/E: non specific. As discussed before, low abdo pain, inability to void, ecchymosis over suprapubic and pelvic region, � Cystography: MUST R/O urethral injury before putting Foley in.Hx and P/E: non specific. As discussed before, low abdo pain, inability to void, ecchymosis over suprapubic and pelvic region, � Cystography: MUST R/O urethral injury before putting Foley in.

38. Investigation Cystography: Gold standard CT Cystography : New trend Peng et al. AJR 1999. Prospective study 55 patients. 5 bladder rupture Cystography VS. CT cystography Ruptures confirmed by Surgery 100% sensitive and specific

39. Investigation� Deck et al. Journal of Urology, 2000. Retrospective study 316 patients with CT Cystography Sensitivity/Specificity = 95% and 100% But 78% and 99% for intraperitoneal rupture Comparable to Cystography alone Identifies other injuries

40. Standard Helical CT Pao et al. Acad Radiol 2000. With IV contrast Misses bladder rupture 100% sensitive if �free fluid� criteria used. Can R/O bladder injury if NO free fluid. Not specific. Not accepted as diagnostic tool. - Some people thought: ��Well, if we�re gonna do a CT for abdominal injury, maybe it will pick up bladder injuries as well��.- Some people thought: ��Well, if we�re gonna do a CT for abdominal injury, maybe it will pick up bladder injuries as well��.

41. Treatment Penetrating injuries: OR Blunt Intraperitoneal: Almost all OR Extraperitoneal: Urethral cath. drainage x 7-10 days.

42. Hematuria Hardeman and al. Journal Urol, 1987. Prospective study 506 patients IVP in all. CT/arteriography/O.R. PRN Shock: BPs<90 at any time 25 Injuries ALL had either Gross hematuria Shock + microhematuria Before I get to the kidney injuries, I want to talk about Hematuria in the context of trauma. What�s the evidence, how should interpret that and what should we do with it. Injuries: 15 kidney, 8 bladder, 2 urethra. Before I get to the kidney injuries, I want to talk about Hematuria in the context of trauma. What�s the evidence, how should interpret that and what should we do with it. Injuries: 15 kidney, 8 bladder, 2 urethra.

43. Hardeman et al. � 365 (52�%) had microhematuria only 174 D/C�ed , F/U and no problem 191 admitted 1 renal contusion (Grade I) 2 minor lacerations (Grade II) No complication

44. Mee et al. Journal Urol, 1989 Prospective 1146 patients IVP = Gold standard ALL significant renal injuries had either: Gross hematuria Microscopic hematuria + shock Intensity of hematuria ? Severity of injury A name to remember is ��Mee et al.�� From San Francisco who did a lot of work on this topic and who is referred to in all the papers discussing this issue. shock: in the field OR in EDA name to remember is ��Mee et al.�� From San Francisco who did a lot of work on this topic and who is referred to in all the papers discussing this issue. shock: in the field OR in ED

45. Gross ��Hematuria��: False + Alphamethyldopa Ibuprofen Levodopa Metronidazole Nitrofurantoin Phenazopyridine Phenolphtalein-containing laxatives Rifampin Beets/berries

46. Microscopic hematuria� 8 major studies 3406 adult blunt trauma with microscopic hematuria and NO shock. 0.23% major renal injuries (?gradeII) No imaging necessary for that group F/U 3-4 weeks to R/O underlying pathology. BUT�

47. Microscopic hematuria� Patients with pelvic # often excluded from studies. Penetrating trauma excluded. Pediatric population excluded ��Rapid Deceleration injuries�� Urinalysis on FIRST urine. Pelvic # : urethral or bladder injuries usually. Most are Renal injuries ONLY. +/- Can�t extend to urethral/bladder injuries. Penetrating trauma = imaging if suspect injury Peds: I will not get into the details, but any child with suspected kidney injury and hematuria (even if microscopic (>50 RBC/hpf) and NO shock) needs imaging. Not the 3rd urine because nobody told the patient or someone threw it away in the sink� So what if the nurse tells you that there is �trace� of blood�do you rely on it? Do you have to spin it?Pelvic # : urethral or bladder injuries usually. Most are Renal injuries ONLY. +/- Can�t extend to urethral/bladder injuries. Penetrating trauma = imaging if suspect injury Peds: I will not get into the details, but any child with suspected kidney injury and hematuria (even if microscopic (>50 RBC/hpf) and NO shock) needs imaging. Not the 3rd urine because nobody told the patient or someone threw it away in the sink� So what if the nurse tells you that there is �trace� of blood�do you rely on it? Do you have to spin it?

48. Dipstick vs. U/A Daum et al. AM J Clin Pathol, 1988. Prospective 178 patients Abdominal Trauma Dipstick AND Microscopic examination Vs. U/A�in the context of trauma�Vs. U/A�in the context of trauma�

49. Daum et al. some authors define it as more than 5, some more that 10 and some don�t define it at all! Normal excretion of RBC in urine corresponds to about 2-3 RBC/hpf. Recommendations today: >5 RBC/hpf. A false positive dipstick result for red blood cells may occur in the presence of either hemolysis (hemoglobinuria) or myoglobinuria. A false-negative result may occur if the patient is taking either vitamin C or captopril. (Emerg Clinic North Am, august 2001). When in contact with an organic peroxidase substrate, hemoglobin catalyzes the reaction and causes subsequent oxidation of a chromogen indicator, which changes color according to the degree and amount of oxidation. recent ingestion of large amounts of vitamin C inhibits peroxidase reaction. some authors define it as more than 5, some more that 10 and some don�t define it at all! Normal excretion of RBC in urine corresponds to about 2-3 RBC/hpf. Recommendations today: >5 RBC/hpf. A false positive dipstick result for red blood cells may occur in the presence of either hemolysis (hemoglobinuria) or myoglobinuria. A false-negative result may occur if the patient is taking either vitamin C or captopril. (Emerg Clinic North Am, august 2001). When in contact with an organic peroxidase substrate, hemoglobin catalyzes the reaction and causes subsequent oxidation of a chromogen indicator, which changes color according to the degree and amount of oxidation. recent ingestion of large amounts of vitamin C inhibits peroxidase reaction.

50. Dipstick vs. U/A Chandhoke et al. J Urol, 1988. Prospective study 339 patients Suspected blunt renal trauma Dipstick AND microscopic examination

51. Chandhoke et al. Specificity very low (<60%). So if positive, always confirm with U/A. So the message to take home is that anything on the dipstick that�s more than trace: U/ASpecificity very low (<60%). So if positive, always confirm with U/A. So the message to take home is that anything on the dipstick that�s more than trace: U/A

52. Kidney Injury Retroperitoneal organ Cushoned by perinephric fat Gerota�s fascia Along T10 - L4 Ribs 10-12 Fixed only through pedicle. 1.2L of blood / min

53. Kidney Injury� Blunt trauma: 80-90% Rapid deceleration / Direct blow MUST be suspected if Trauma to back / flank / lower thorax / upper abdomen Flank pain / low rib # Hematuria / Ecchymosis over the flanks Sudden decelaration / Fall from height. Lumbar transverse process # - However, 5-10% will NOT have hematuria�- However, 5-10% will NOT have hematuria�

54. Lumbar Transverse Process Fractures Prospective study (1994-1999) Lumbar spine # 191 patients Transverse # in 29% Abdominal organ injuries 47% vs. 6% Kidney: 1/3 Liver: 1/3 Spleen: 1/4 abdominal organ injuries�I don�t need to tell you that it was statistically significant� Correlated by another study: Patten et al. Frequency and Importance of Transverse Process Fractures in the Lumbar Vertebrae at Helical Abdominal CT in patients with Trauma. Radiology; 215:831-834; 2000.abdominal organ injuries�I don�t need to tell you that it was statistically significant� Correlated by another study: Patten et al. Frequency and Importance of Transverse Process Fractures in the Lumbar Vertebrae at Helical Abdominal CT in patients with Trauma. Radiology; 215:831-834; 2000.

55. Classification of Injury 5 Classes of Renal Injury : - created by the American Association for the Surgery of Trauma.- created by the American Association for the Surgery of Trauma.

56. Grade I Contusion Hematuria Urologic studies N Hematoma Subcapsular Non expanding Parenchyma N

57. Grade II Hematoma Perirenal Nonexpanding Laceration < 1.0 cm Renal cortex only No urinary extravasation

58. Grade III Laceration > 1.0 cm Renal cortex only No urinary extravasation Intact collecting system

59. Grade IV Laceration Renal cortex Renal medulla Collecting system Vascular Main renal artery/vein injury with contained hemorrage.

60. Grade V Completely shattered kidney. Avulsion of renal hilum (pedicule) which devascularizes kidney.

61. Pedicule Injury -The adventice and the media being much more elastic than your intima, they stretch but the intima tears.-The adventice and the media being much more elastic than your intima, they stretch but the intima tears.

62. Organ Injury Severity Scale Validated lately: Journal of Trauma, 2001 Predicts the need for surgery Need for surgery ; nephrectomy rates: Grade I: 0 ; 0% Grade II: 15 ; 0% Grade III: 76 ; 3% Grade IV: 78 ; 9% Grade V: 93 ; 86%

63. Investigation IVP Used to be intial exam of choice. Very poor sensitivity for penetrating injury Limitation in staging renal injuries Not 1st choice anymore. Only if pt unstable. Contrast CT Study of choice if stable More sensitive and specific for staging Detects other abdominal injuries Angiography reserved for inconclusive CT.Angiography reserved for inconclusive CT.

64. Management Penetrating trauma: Imaging for ALL (9%: NO hematuria) Blunt trauma Imaging: Gross hematuria Microscopic hematuria (?5 RBC/hpf) + shock (BPs?90) Any child with > 50 RBC / hpf penetrating trauma with suspected renal injury (location of wound, direction of projectile�) Shock in the field OR in the ED.penetrating trauma with suspected renal injury (location of wound, direction of projectile�) Shock in the field OR in the ED.

65. Management� Absolute indication for Surgery: Uncontrollable renal hemorrage Multiply lacerated, shattered kidney Main renal vessels avulsed Penetrating injuries usually Grade I-II conservative Grade III-IV Conservative if stable hemodynamically vs. surgery Grade V Surgery

67. Back to Jeremy� First urine: Dipstick +++ (15 RBC/hpf) Pelvic x-ray: Straddle #

69. Jeremy� First urine: Dipstick +++ (15 RBC/hpf) Pelvic x-ray: Straddle # Keypoints� BP: 85/50 on scene Microhematuria Pelvic # NO FOLEY -What are you worried about now? Answer: URETHRA +/- Bladder�but also kidney (shock).-What are you worried about now? Answer: URETHRA +/- Bladder�but also kidney (shock).

70. Jeremy� Urology consulted Retrograde urethrogram: N CT cystogram: N Contrast CT to look for renal injury: Grade II renal injury.

71. Conclusion No Foley if you suspect urethral trauma Gross hematuria OR microhematuria + Shock = GU Trauma. Pelvic # + Microhematuria GU investigation Don�t remove Foley if you suspect a partial tear of urethra afterwards. Microhematuria alone : No imaging �but F/U. In peds: Imaging for ALL hematuria. To be excellent at dealing with a trauma patient doesn�t only mean to be good at taking care of the difficult airway and putting chest tubes, though more spectacular. To be excellent at dealing with a trauma patient doesn�t only mean to be good at taking care of the difficult airway and putting chest tubes, though more spectacular.

72. The End