All posts by TheTraumaPro

CT Cystography For Bladder Trauma

Bladder injury after blunt trauma is relatively uncommon, but needs to be identified promptly. Nearly every patient (97%+) with a bladder injury will have hematuria that is visible to the naked eye. This should prompt the trauma professional to obtain a CT of the abdomen/pelvis and a CT cystogram.

The CT of the abdomen and pelvis will identify any renal or ureteral (extremely rare!) source for the hematuria. The CT cystogram will demonstrate a bladder injury, but only if done properly!

During most trauma CT scanning of the abdomen and pelvis, the bladder is allowed to passively fill, either by having no urinary catheter and having the patient hold it, or by clamping the catheter if it is present. Unfortunately, this does not provide enough pressure to demonstrate small intraperitoneal bladder injuries and most extraperitoneal injuries.

The proper technique involves infusing contrast into the bladder through a urinary catheter. At least 350cc of dilute contrast solution must be instilled for proper distension and accurate diagnosis. This can be done prior to the abdominal scan. Once the initial scan has been obtained, the bladder must be emptied and a focused scan of just the bladder should be performed (post-void images). Several papers have shown that this technique is as accurate as conventional retrograde cystography, with 100% sensitivity and specificity for intraperitoneal ruptures. The sensitivity for extraperitoneal injury was slightly less at 93%.

Bottom line: Gross hematuria equals CT of the abdomen/pelvis and a proper CT cystogram, as described above. Don’t try to cheat and passively fill the bladder. You will miss about half of these injuries!

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Reference: CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 187(5):1296-302, 2006.

Intraperitoneal bladder injury

Intraperitoneal bladder rupture

Extraperitoneal bladder

Extraperitoneal bladder injury

More on Distracting Injury and Spine Clearance

There is a lot of angst out there among trauma professionals when it comes to clearing the cervical spine and possible distracting injuries. I’ve written about this before, and the most important technique I use is to try to see if the patient is aware of pain in areas distant from the suspected distraction.

A recent prospective study looked at injury patterns and c-spine clearance in over 9,000 trauma patients at a single Level I trauma center. Of those, 101 were evaluable (not intoxicated, no head injury) and actually had a cervical fracture. 96% of them were symptomatic, despite the majority having what would normally be considered a distracting injury (87%). Of the 4 who did not have pain or tenderness on examination of the neck, every one of them had a distraction.

There was a pattern as to which “distracting” injuries were really a distraction. All four of the asymptomatic patients had bruising or tenderness to the upper anterior chest, which diverted their attention away from their neck. Other injuries caused pain in some of these patients, but it was outweighed by the chest wall pain.

Bottom line: Distracting injury is currently defined too liberally, which results in lots of patients getting lots of unneeded cervical spine imaging. Although this study is small, it adds one more piece of information to the c-spine clearance puzzle. I personally will add this to my current practice and clear the cervical spine if:

  • The patient is aware of multiple sources of pain
  • Subjective pain scale overall is less than 6 (otherwise provide better pain control!)
  • There is no pain/tenderness/injury to the upper chest 

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Reference: The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study. J Trauma 71(3):528-532, 2011.

Explain This! The Answer

This patient was running from an assailant at top speed and fell, tumbling for several feet. Medics found him in this position and pondered how to secure him for transport. eventually they just used straps and belts to hold him on a backboard.

The injury is an interesting one. He has a femur fracture, but there is a twist (literally). If he was a contortionist and had found a way to bend his knee toward his head, his toes would point to his face. If you look at the thigh, twisted muscle bellies can be seen.

The diagnosis is a mid-shaft femur fracture with a 180 degree rotation of the distal portion.

Using The Slide Board In The ED

I’ve written several times on the importance of getting patients off the backboard promptly in the ED. Many hospitals use slide boards to facilitate patient movement on and off the ED cart when undergoing imaging studies. How should we manage the use of this device?

There is no difference between a backboard and a slide board to the patient. It’s hard and uncomfortable to lie on for any period of time, and can cause soft tissue injury. To trauma professionals in the ED it is thinner, less bulky, easier to manipulate, and does not interfere with xrays as much. We tend to pay less attention to it than a backboard. Although it does not immobilize the spine as well as a backboard does, the difference is not clinically significant (in a cooperative patient). Remember, if your patient actually has a spine fracture, they will be placed on logroll precautions on a soft mattress only somewhere in your hospital! No stiff boards of any kind!

Slide board management tips:

  • Slide boards are for blunt trauma only! Patients with penetrating injury may need an upright chest xray in the ED and the board won’t flex enough.
  • Insert the slide board in any patient who will be getting several diagnostic studies. For trauma activation patients, this can occur as you roll them off the backboard.
  • As soon as diagnostic studies are done, remove the slide board
  • If there are unforeseen delays, remove the slide board and reinsert when ready to move
  • Remember that the soft tissue timer is counting down as soon as the patient is placed on a backboard or slide board
  • Plan an efficient road trip through diagnostic studies for your patient. This allows you to minimize time on the board. 
  • Repeated logrolls onto and off of the slide board are discouraged. Every roll is an opportunity for mishap.

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