Hematuria after Blunt Trauma
Ureter injuries may have only microscopic or none (J Urol. 2003 Oct;170(4 Pt 1):1213-6.) If there is only microscopic, you can ignore if:
- Pt doesn’t have SBP<90 at any point
- Not severe deceleration injury
- No gross blood
Urethral Trauma-urogenital diaphragm separate from anterior in males Foley placement-use 14 or 16F
Retrograde Urethrogram (RUG)
Oblique patient positioning if possible, First shoot KUB, Place 60 cc syringe tip in urethra filled c ½ strength contrast. Shoot film during last 10cc
- 6 or 7 FR foley
- Inflate just enough to keep it in
- Full strength contrast
- 30-60 ml
- 2 views
Trauma Professional’s Method
The technique is simple. The following items are needed: A urine specimen cup A tube of KY jelly (not the little unit dose packs) A bottle of renografin or ultravist contrast A 50-60 cc Toomey syringe (slip-tip) A fluoroscopy suite Pour 25cc of contrast and 25cc of KY jelly in the specimen cup, cap it and shake well. I prefer this mixture because it creates a contrast jelly which is less likely to dribble out when injected. Draw the contrast jelly up into the syringe. Under fluoro, insert the tip of the syringe into the penis and pull it toward yourself, pinching the meatus around the tip of the syringe. Slowly inject all the contrast, watching the contrast column on the fluoro screen. Once there is easy flow into the bladder, you can stop the study. If you see extravasation into the soft tissues, stop the study and call Urology. The advantages to using this technique are: The contrast/jelly mix creates a contrast gel that is less likely to leak from the meatus when injected The jelly makes it easy to insert the catheter if no urethral injury is detected Important tip: If you use the contrast jelly technique, be prepared to flush the urinary catheter with saline once it is inserted. The jelly almost always plugs it up, resulting in no return of urine when inserted. can try 1 shot at placing foley cath (J Trauma 2007;62(2):330) Bladder Trauma-usually presents with gross hematuria
Renal-often microscopic hematuria. Eval c CT scan. C penetrating, hematuria may be absent, must go by mechanism alone updated J Trauma 201170(1):35 EAST RECOMMENDATIONS A. RENAL TRAUMA 1. Level I There is insufficient Class I and Class II data to support any standards regarding management of renal trauma. 2. Level II 1) Preliminary vascular control does not decrease blood loss or increase renal salvage. ©Copyright 2004 Eastern Association For The Surgery of Trauma 5 2) Conservative management of shattered but perfused kidneys in hemodynamically stable patients with minimal transfusion requirements will result in a low incidence of complications, which can usually be treated with endourological or percutaneous methods. 3. Level III 1) Preliminary vascular control may prolong operative time 2) The success of nonoperative management may be enhanced by the use of angiographic embolization. 3) Nonoperative treatment of renal lacerations from blunt trauma associated with extravasation is associated with few complications, which can usually be treated with endourological or percutaneous methods. 4) Conservative management of major renal lacerations associated with devascularized segments is associated with a high rate of urologic morbidity (38 – 82%). In patients who present with a major renal laceration associated with devascularized segments, conservative management is feasible in those who are clinically stable with blunt trauma. The physician must be especially aware of the probable complications within this subset of patients. 5) Operative exploration of the kidney should be considered in patients with major blunt renal injuries with a devascularized segment in association with fecal spillage or pancreatic injury. 6) Nonoperative treatment of penetrating renal lacerations is appropriate in
hemodynamically stable patients without associated injuries who have been staged completely with CT scan and/or IVP. A high index of suspicion is needed to avoid ureteral injuries if a course of nonexploration is chosen. 7) Penetrating Grade III or IV injuries are associated with a significant risk of delayed bleeding if treated expectantly. Exploration should be considered if laparotomy is indicated for other injuries or if the injury is not completely staged prior to exploratory laparotomy for other injuries. B. RENOVASCULAR TRAUMA 1. Level I There is insufficient Class I and Class II data to support any standards regarding management of renovascular trauma. 2. Level II There is insufficient Class II data to support any recommendations regarding management of renovascular trauma. 3. Level III There is insufficient Class III data to support any recommendations regarding management of renovascular trauma.
Complications Following Renal Trauma Arch Surg. 2010;145(4):377-381. Conclusions Selective nonoperative management is safefor blunt and penetrating kidney injuries. Patients managedwith nephrorrhaphy are at higher risk for local kidney-relatedcomplications than other therapeutic modalities. Patients withminor or moderate kidney injuries treated with exploration ofthe kidney are more likely to develop local complications thanthose treated without exploration.
After 45 minutes the kidney has suffered irreverisble warm ischaemia – revascularisation is no longer appropriate after 48 hours! Tim > At what point did a deliberate revascularization become unworkable due to > renal artery scarring and resultant hypertension? > > ck > > > In a message dated 6/1/2010 01:15:38 Central Daylight Time, > firstname.lastname@example.org writes: > > Hi Dr Khattar > > Two options: > Refer him to someone with angio-embolisation facilities and coil the > ipsilateral renal vessel to prevent later reperfusion with hypertension – > the actual kidney will atrophy and not need removal in this case – the > option I would take if possible! > Take out the kidney with the same intention is the other option.</
Testicular Trauma/Scrotal Trauma Get UA If severe swelling, Doppler or testicular scan Do not need to image sole microscopic hematuria without associated signs and symptoms (Emerg Med J 19:322, 2002) Retrograde Urethrogram: Technique · A retrograde urethrogram is performed with the patient supine · An initial KUB is obtained for comparison. o Incidental findings on the KUB suggestive of GU injury include: § Loss of the psoas shadow 2° to retroperitoneal blood § Spinal curvature, usually concave toward the site of injury because of splinting § Pelvic Fracture § Lower Rib or Transverse Process fractures · A Foley catheter is passed approximately 1 to 2 cm to the fossa navicularis and the balloon is inflated with 1 to 2 mL of saline. · Alternatively a 60-cc Toomey syringe with a Christmas tree or Cooke adapter may be gently inserted until snug. 9 · Lateral traction is applied to the penis and 60 mL of water-soluble contrast material is injected over 30 to 60 seconds. · The radiograph is exposed as the last 10 mL of contrast material is injected. · Extravasation of contrast material or failure of contrast material to reach the bladder is diagnostic of urethral injury, mandates urologic consultation, and precludes the passage of a urethral catheter by the emergency physician · If a Foley is in place, a lubricated pediatric feeding tube can be placed, and the retrograde urethrogram performed.
CT Cystography article Classification of Bladder Injuries 1 Bladder Contusion 2 Intraperitoneal Rupture 3 Interstitial Bladder Injury 4 Extraperitoneal rupture 4a Simple 4b Complex 5 Combined Injuries CT with just IV contrast is inadequate Delayed Imaging can increase this sensitivity Filling the bladder with 350 cc of contrast and then doing CT is far more sensitive Perform in patients with known pelvic fxs, gross hematuria, or severe pelvic trauma Mix 50 cc Hypaque 60 and 450 cc NS, make sure at least 350 cc goes into the bladder postdrainage images are not really necessary (Radiographics 2000;20:1373) Conclusions: CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT cystography can be performed as an integral part of the CT screening undergone by many blunt trauma patients and, in the vast majority of these patients, it can alleviate the need for a separate conventional cystogram. (J Trauma 2006;61(2), August 2006, pp 410-422) CT cystography was performed in the following manner. When the patient was placed on the CT table, the urinary drainage bag was separated from the Foley catheter and the Foley catheter was suctioned with a 60-mL catheter-tipped syringe until the urinary bladder was completely emptied. A premixed 0.9% sodium chloride IV fluid bag containing 350 mL of cystography contrast (see formulations below) was connected to the Foley catheter via a vented IV tubing set and a large catheter adapter (part #8039, Procedure Products Research, Vancouver, WA). The contrast bag was raised to a height of 3 to 4 feet above the patient using an IV pole. The contrast was allowed to drip into the bladder by gravity while the CT technologist performed routine prescanning procedures. Imaging was initiated after one of the following endpoints was reached: (1) 350 mL of contrast was completely instilled into the bladder, (2) continued bladder detrusor activity limited the volume that could be instilled to less than 350 mL despite adequate time for bladder relaxation, or (3) the patient reported significant abdominal/pelvic discomfort, necessitating the cessation of further contrast instillation. A variety of CT cystography contrast concentrations, ranging from 12 to 32 mg of iodine (mgI) per mL, were tried during the first 3 years of the study (250 patients). Based on the preferences of the interpreting radiologists after the initial evaluation period, the concentration used for all subsequent patients was 28 mgI/mL. This final CT cystography contrast formulation consisted of 35 mL of iothalamate meglumine 60% ionic contrast (Conray; Mallinckrodt, St Louis, MO) mixed with 315 mL of 0.9% sodium chloride in a 250-mL IV fluid bag; the bag distends to hold the extra volume. CT images of the abdomen and pelvis, including the contrast-filled bladder, were obtained using the standard trauma technique described above (Fig. 1). No additional pelvic scans or postdrainage scans were performed, unless they were needed to help clarify an area of diagnostic uncertainty. In 9% of cases (44 of 495), CT cystography was performed as a separate examination immediately after the initial abdominal/pelvic CT, with reimaging of the lower abdomen and entire pelvis after retrograde filling of the bladder as described above. Conventional cystography, when used, was performed after the abdominal/pelvic CT, with the exact timing dictated by the patient’s clinical condition and medical management (with a range of 0.512 hours after the CT was performed). Conventional cystography was performed in the following manner. The Foley catheter was suctioned with a 60-mL syringe, as described above. A preliminary anteroposterior (AP) radiograph of the pelvis was obtained. A 300-mL bottle of diatrizoate meglumine 30% ionic contrast (150 mgI/mL) (Reno-Dip, Bracco Diagnostics, Princeton, NJ) was connected to the Foley catheter via vented IV tubing set with a large catheter adapter. The contrast was instilled into the bladder via gravity in the same manner and with the same endpoints as described for CT cystography. The Reno-Dip bottle contains only 300 mL of contrast, so an additional 50 mL of contrast was added in most patients before completion of the gravity drip to bring the total amount instilled to 350 mL. An AP radiograph was obtained of the pelvis after instillation of approximately 100 mL of contrast, and again after instillation of 350 mL of contrast (or after a bladder filling endpoint was reached, as previously described). Oblique radiographs were obtained if the patient could be safely turned, followed by an AP radiograph after draining the contrast from the bladder. If there was any uncertainty as to whether residual contrast seen on the postdrainage radiograph represented extravasated bladder contrast, 150 mL of 0.9% sodium chloride solution was instilled into the bladder by gravity and then a repeat AP radiograph was obtained after draining the bladder a second time. The vast majority of the conventional cystograms were performed using portable radiographic equipment in the trauma emergency room; the others were performed using fixed radiographic equipment, without fluoroscopic imaging, in the radiology section of the emergency room. Appropriate cystography contrast volume adjustments for children aged 2 to 11 years were made using the following formula: Volume of contrast to be instilled = (age in years + 2) × 30 mL. Before CT imaging, these patients had retrograde gravity-drip infusion of 350 mL of contrast (21 mgI/mL) into the bladder, along with oral and IV contrast. CT imaging of the abdomen and pelvis was performed routinely, without delayed or separate bladder imaging. In 1998, Vaccaro et al.18 described their technique for CT cystography, which involved routine abdominal/pelvic CT with oral and IV contrast and retrograde bladder filling with 350 mL of contrast (29 mgI/mL). Postdrainage films are an essential component of the conventional cystogram because the contrast-filled bladder may obscure a small amount of extravasated contrast on the two-dimensional radiograph. However, computed tomography allows for evaluation of the pelvis via two-dimensional, cross-sectional images, and extravasated contrast can be visualized despite the presence of a bladder distended with contrast (Fig. 4). For this reason we do not routinely include postdrainage images as part of our CT cystography technique. Indications for Evaluation for Bladder Injury Which patients with blunt abdominal/pelvic trauma should undergo imaging evaluation for bladder injury? This is a difficult question. Ideally, a set of criteria could be established that would include all patients with bladder injury and minimize the number of studies performed on patients with noninjured bladders. In the study reported here, our inclusion criteria for bladder imaging were gross hematuria, pelvic fracture, and/or high clinical suspicion. A large majority of bladder ruptures are associated with gross hematuria; therefore, many authors suggest that the presence of gross hematuria is a strong indication for bladder imaging in patients with blunt trauma.1,21,22 To add to this body of literature, we report that in our study of 495 patients, 45 of the 46 patients with bladder injury would have undergone cystography if gross hematuria had been the only indication for blunt bladder imaging. To diagnose the remaining patient, who had microscopic hematuria with less than 25 red blood cells per high-powered field (RBC/HPF), pelvic fracture would have had to be added to the inclusion criteria, and it was. Morgan et al.22 reported a series of 157 patients prospectively evaluated for bladder injury with CT cystography, 12 of who had bladder ruptures. In that series of 12 bladder injuries, 2 patients had gross hematuria, 6 patients had gross hematuria and pelvic injury, and 4 patients had pelvic injury with large microscopic hematuria, which the authors defined as greater than 25 RBC/HPF. Furthermore, the study found no bladder ruptures in the 10 patients with pelvic fracture and small microscopic hematuria (less than 25 RBC/HPF). No bladder ruptures were found in the 99 patients who had neither gross hematuria nor pelvic injury. Iverson and Morey 23 reviewed the literature from 1980 to 2000 and concluded that gross hematuria with pelvic fracture was the only absolute indication for cystography after blunt trauma. They went on to state that their review of existing data did not support the need for lower urinary tract imaging in all patients with either pelvic fracture or gross hematuria alone. However, the authors concluded that gross hematuria alone, pelvic fracture with microscopic hematuria, or even isolated microscopic hematuria are relative indications for cystography when clinical indicators of bladder rupture are also present (e.g., suprapubic pain, inability to void, low urine output, perineal trauma, etc.). A review of our trauma registry showed that a number of patients who presented to the trauma center during the time of this ongoing investigation with findings that fit the study’s criteria for CT cystography (gross hematuria, pelvic fracture, or high clinical suspicion) received only conventional abdominal/pelvic CT. One such patient, a 70-year-old woman involved in a motor vehicle collision resulting in pelvic fracture and microscopic hematuria, did not undergo bladder evaluation with either CT cystography or conventional cystography. The patient was later found to have an EP-type bladder rupture, which was thought to have greatly contributed to the sepsis and death that followed early removal of her Foley catheter. It is because of such cases that we recommend the inclusion of pelvic fracture as an indication for cystography in patients with blunt abdominal/pelvic trauma, despite the absence of gross hematuria. Since the vast majority of hemodynamically stable patients with significant blunt torso trauma receive abdominal/pelvic CT imaging, and our described method of CT cystography has proven to add little time or cost to the procedure, we advocate relatively liberal use of CT cystography to avoid missed diagnoses.