Week 30: Trauma 5/5: Abdominal/GU

The patient has a penetrating abdominal injury with evisceration of abdominal contents. Indications for the OR in penetrating abdominal injury include unstable vital signs, peritonitis w/ a +FAST examination, evisceration, and transabdominal GSW.

Patients with fractures of the bony pelvis are at high risk for hemorrhage due to the close proximity of the vascular structures to the pelvic bones. The internal iliac arteries and their subsequent branches provide most of the blood supply to the pelvic region. Most traumatic pelvic bleeding is venous, but in unstable patients an arterial source is suggested. In this patient with fractures and persistent hemodynamic instability without hemoperitoneum, the source of bleeding is likely the pelvis. After initial attempted stabilization with an external pelvic binder (either a sheet or commercial device), the patient needs angiography and embolization in interventional radiology. Angiography has very high success rates at controlling pelvic hemorrhage.

The correct answer is retrograde urethrogram to evaluate for urethral injury. Posterior urethral injuries can occur with pelvic fractures. A bladder fracture is also a possibility and a retrograde cystogram should be performed after the urethrogram to assess for bladder injury given the open book pelvic fracture on x-ray. A foley catheter is contraindicated until urethral injury has been excluded. IVP is rarely performed currently as CT scan can evaluate for renal injury reliably. Retrograde cystogram should be done as well but after a retrograde urethrogram. Intravenous pyelography may be done if suspect kidney injury but blood at the urethral meatus in the context of a pelvic fracture is more suggestive of a urethral or bladder injury. Placement of a foley catheter is contraindicated

The presence of gross hematuria in the setting of trauma signifies a urologic injury until proven otherwise. Gross hematuria suggests either a lower or upper urinary tract injury. Bladder injury (e.g. rupture) is suggested by lower abdominal pain and tenderness or a positive FAST examination on evaluation of the pelvis. Urethral injuries may present with blood at the meatus in which case a retrograde urethrogram is indicated. Blunt trauma accounts for approximately 90% of renal injuries and 1-5% of hospitalized trauma patients have a renal injury. In most cases, clinically significant renal injuries are associated with gross hematuria. Rarely, a significant injury is found with microscopic hematuria but also hemodynamic instability. Therefore, if renal injury is suspected, gross hematuria in the hemodynamically stable patient dictates further imaging evaluation.

The spleen is the most common organ injured in adults in blunt abdominal trauma. Most blunt abdominal trauma results from motor vehicle collisions. Many splenic injuries, including high-grade lacerations, may be managed conservatively in the hemodynamically stable patient without other significant intraabdominal injuries.

The correct answer is between the spleen and the diaphragm. Fluid is rarely seen between the spleen and kidney. Most commonly it is between the spleen and diaphragm, or simply around the spleen.

When a patient presents after suffering blunt abdominal trauma and has a concerning abdominal examination but a negative workup, decisions about appropriate management can be challenging. In this particular patient, the negative CT scan and FAST results are reassuring in terms of solid organ injury, but there is potential for other serious injuries, such as hollow viscus injury or pancreatic injury. The seatbelt sign (ecchymosis on the abdomen) suggests that the patient could have these injuries, so a period of observation in the hospital is warranted. Discharging the patient without a period of observation either in the hospital or in the emergency department creates the potential for the patient to suffer significant complications from undiagnosed intraabdominal injury. Diagnostic peritoneal lavage would be helpful in this patient if grossly positive but might not otherwise definitively determine the indication for surgical management. The formal abdominal ultrasound examination done in the radiology department is no more accurate than a FAST examination done by an experienced provider for identifying hollow viscus injury or acute pancreatic injury.

The patient is suffering from an acute traumatic uterine rupture a rare complication following blunt and penetrating abdominal trauma. The classic signs include maternal shock, abdominal pain, peritoneal signs, abnormal fetal lie, easily palpable fetal anatomy and fetal demise. The use of a lap belt alone increases the risk of developing uterine rupture and placental abruption. The patient should be aggressively resuscitated and emergent surgical and obstetric consultation is necessary for operative repair.

CT imaging is excellent in detecting solid organ injury (e.g. kidney, liver, spleen, pancreas) but not good at detecting mesenteric hematoma/tears or hollow viscus injury.

Gross hematuria is the most common sign of bladder injury and occurs in more than 95% of the cases. Bladder injury most commonly results from blunt motor vehicle trauma and 80% are associated with fracture of the bony pelvis. Bladder injuries include contusions, intraperitoneal and extraperitoneal ruptures and combination ruptures. Other signs of bladder rupture include suprapubic and lower abdominal pain, inability to urinate, pelvic fracture, and blood at the urethral meatus. Blood at the urethral meatus is a sign of underlying urethral or bladder injury, although is not the most common sign for bladder injury. A high-riding prostate is a sign of urethral injury, not bladder injury. An inability to urinate is a sign of bladder injury, however is not the most common sign.