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ED Management of GU & Pelvic Trauma - Dr. Gibbs

4/17/2014

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Picture
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. 
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  • RESIDENCY
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    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Prospective Visiting Students
    • UNC/Wake Forest Students
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction