ED Management of GU & Pelvic Trauma - Dr. Gibbs

GU & Pelvic Trauma Basics

• 10% of injuries involve GU track
• May not be evident during the intial exam 
• Hematuria is most important sign of GU injury!
• Signs: Lower abdominal pain, blood urethral meatus or introitus, abnl prostate, gross
  hematuria; scrotal ecchymosis is usually delayed
  

• Lower tract = urethra, bladder, external genitalia
• Lower tract injuries- pelvic fracture, straddle injuries, direct blow, penetrating trauma
  
• Anterior urethra - direct blow - blood at meatus, ecchymosis, abnl prostate
  
• Posterior urethra - due to pelvic fractures - pain, dysuria, hematuria
  
• Upper tract = ureter & kidney 

Bladder injury
- Pelvic fracture, direct blow, penetrating injury - bladder rupture in 5-10% of pelvic fractures (more fractures = higher risk of injury)
- Intraperitoneal - dome is the weakest part (surgical repair)
- Extraperitoneal - manage with foley 


Evaluation of the GU Tract

• Should be done in retrograde fashion if patient is stable - urethrogram > cystogram > CT
• Urethrogram - hematuria, blood at meatus, inability to void, abnl prostate exam 

- How to: 60 cc syringe with a Christmas tree adapter - full strength contrast stretch penis to length, instruct patient to relax perineum, firm seal at meatus, inject 30-60 cc contrast, expose film after 50% injected
- Look for extravasation & look for contrast in bladder - if no contrast in the bladder = complete disruption of urethra - this requires surgery; some partial injuries can be managed with Foley catheter.

• Cystogram - lower abdominal pain and gross hematuria or really jacked up pelvis with microscopic hematuria; 

-How to - Foley catheter in, 400-500 cc contrast, clamp foley, shoot single A film, drain bladder, shoot post-void AP film


Upper Tract Injury
- flank bank or abdominal pain with gross hematuria or microscopic hematuria with shock 
- 85% of renal injuries are secondary to blunt trauma; 
- any penetrating trauma near this area requires evaluation of kidneys 
- management depends on grade of injury
- Ureteral injuries - easy to miss; tend to present late
 

---

---

Pelvic Ring Fractures
- pelvis is strong - takes a lot of force to break it; 

Assess for injuries:
a. Proximate - urethra, bladder, vagina, sciatic nerve
b. Distant - brain, chest, aorta, intra-abdominal 

Who to image- physical findings suggestive of injury, shock 

Types:

1. Lateral compression - horizontal anterior ring fracture- look for sacral fracture  
2. AP - open book fracture - high risk of bleeding out - "mac daddy of pelvic fracture"
3. Vertical Sheer - high risk of vascular injury - if no femur fracture put in traction
4. Posterior ring disruption - increased mortality 

Unstable patients with pelvic fracture
- angio vs OR: if grossly positive FAST, OR first.  If not, angio first.