Trauma
Question 207 of 216
A 72 year old man is brought to the Emergency Department after crashing his ride on lawnmower into a garage door. He has bruising across his abdomen. The doctor performing a primary survey notes blood at the urethral meatus. What is the most useful investigation to locate the source of blood?
Answer:
- Background:
- Posterior urethral tears are often associated with pelvic fractures. Urethral injury may also result (in the absence of fracture) from blows to the perineum (especially falling astride).
- Clinical features
- Look for perineal bruising and blood at the external urethral meatus.
- Investigations and management:
- If urethral injury is suspected, do not attempt urethral catheterisation, but refer urgently to the urology team. Some urologists advocate a single gentle attempt at urethral catheterisation. Other options are to perform a retrograde urethrogram to assess the extent of the urethral injury or to undertake suprapubic catheterisation and subsequent imaging.
Renal trauma
- Background:
- Most renal injuries result from direct blunt abdominal trauma, the kidney being crushed against the paravertebral muscles or between the twelfth rib and the spine. Indirect trauma (e.g. a fall from a height) can tear the major blood vessels at the renal pedicle or rupture the ureter at the pelviureteric junction. Penetrating injuries are relatively rare. Many patients with renal trauma also have other important injuries, which may obscure the diagnosis of the renal injury. Children are particularly prone to renal injuries. Trauma may uncover congenital abnormalities, hydronephrosis, or occasionally incidental tumours.
- Clinical features:
- Most patients provide a history of a blow to the loin or flank and have loin pain followed by haematuria (which may be delayed). The loin is tender and there may be visible bruising or abrasions. Worsening renal pain may indicate progressive renal ischaemia. Perinephric bleeding can cause loin swelling and a palpable mass. Haematuria may be absent in severe injuries in which there are renal vascular tears, thrombosis, or even complete ureteric avulsion.
- Investigations:
- Look for, and record, visible haematuria and test for microscopic haematuria. Get venous access, and send blood for FBC, U&E, glucose, clotting screen, and group and save. Urgent abdominal CT is needed if there is frank haematuria or if the patient was shocked (but is now stable) and has frank or microscopic haematuria. The surgical team should be involved before a CT scan is arranged. Patients should be haemodynamically stable for transfer to CT scanning. Intravenous urography (IVU) is unnecessary if contrast enhanced CT is planned or has been done. FAST (USS) shows renal morphology and confirms the presence of two kidneys, but it does not demonstrate function. It may reveal intraperitoneal blood. Selective angiography: this is occasionally helpful. Stable patients with isolated microscopic haematuria do not necessarily need urgent IVU or CT but require review and appropriate follow- up (e.g. repeat urinalysis at the GP in a few days’ time).
- Mangagement:
- Most blunt renal injuries settle with bed rest and analgesia. Give prophylactic antibiotics after consulting the surgical team and according to local policy. Repeat and record pulse, BP, and T°. Patients with penetrating renal injuries and severe blunt renal trauma need urgent expert urological assessment ± emergency surgery— the warm ischaemic time of a kidney is only ~2hr. Resuscitate with blood and give IV analgesia and antibiotics.
Bladder trauma
- Background:
- The bladder most often ruptures into the peritoneal cavity, as a result of a direct blow to the lower abdomen. These injuries often occur in individuals with distended bladders. Bone fragments from a fractured pelvis may also penetrate the bladder.
- Clinical features:
- Lower abdominal tenderness ± peritonism may be associated with haematuria or an inability to pass urine. Look for perineal bruising, and check for fresh blood at the external urethral meatus. Perform a rectal examination to check for the position of the prostate and the integrity of the rectum.
- Investigations and management:
- CT will identify significant bladder injuries and any associated pelvic fractures. If there is no sign of urethral injury, pass a catheter to check for haematuria. Refer to the urology team. A cystogram will demonstrate extravasation from a bladder injury. Refer patients with intraperitoneal rupture for laparotomy and repair. Extraperitoneal ruptures may heal with catheter drainage and antibiotics.
Urethral trauma
- Background:
- Posterior urethral tears are often associated with pelvic fractures. Urethral injury may also result (in the absence of fracture) from blows to the perineum (especially falling astride).
- Clinical features
- Look for perineal bruising and blood at the external urethral meatus, and perform a rectal examination (an abnormally high- riding prostate or an inability to palpate the prostate imply urethral injury).
- Investigations and management:
- If urethral injury is suspected, do not attempt urethral catheterisation, but refer urgently to the urology team. Some urologists advocate a single gentle attempt at urethral catheterisation. Other options are to perform a retrograde urethrogram to assess the extent of the urethral injury or to undertake suprapubic catheterisation and subsequent imaging.
Scrotal and testicular trauma
- Scrotal injuries
- Wounds involving the scrotal skin may need to be sutured (preferably with absorbable sutures)— most heal rapidly. Refer for investigation if there is complete scrotal penetration with the attendant risk of damage to the testis, epididymis, or vas deferens. If the testis is visible through the wound, refer for surgical exploration and repair in theatre.
- Testicular injuries
- Blunt injury to the scrotum/ testis may result in a scrotal haematoma or testicular haematoma or rupture. All of these are very painful— provide good analgesia. Further management depends upon the exact diagnosis. USS will help to distinguish between a haematoma and testicular rupture. Involve the urology team— haematomas may respond to conservative measures, but testicular rupture requires urgent surgical exploration and repair.
Penile trauma
- Minor superficial tears
- Relatively common. Most involve the frenulum. Patients report pain and bleeding following sexual intercourse. Bleeding usually responds to local pressure (if not successful, consider tissue glue or refer to the surgical team). Once bleeding has stopped, advise abstinence from sexual activity for ~10 days to allow healing to occur and prevent recurrence.
- Fracture of the penis
- This occurs infrequently. It involves injury to the tunica albuginea of the erect penis. The result is penile tenderness and swelling. Refer to the urologist for urgent surgical exploration, evacuation of haematoma, and repair.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
