Hematuria ranges from microscopic to gross. Microscopic means blood that can only be seen with a microscope, and gross means visible to the naked eye. In trauma, we only care about gross hematuria, which ranges from the faintest of pink to the deepest red.
In trauma, gross hematuria is a result of an injury to kidney, ureter or bladder. Blunt injury to the ureter is so rare it’s reportable, so you can pretty much forget that one unless the mechanism is extreme. So you really just need to focus on kidney and bladder.
Any victim of blunt trauma that presents with visible hematuria needs to be evaluated by CT of the abdomen and pelvis with an added CT cystogram. Standard CT technique is done without a urinary catheter, or with the catheter clamped. Only 50% of bladder injuries show up with this technique.
CT cystogram is an add-on to the standard CT, and consists of the administration of contrast into the bladder which is then kept under pressure while the scan is done. Delayed slices through the pelvis after the bladder is depressurized and emptied is routine. Nearly 100% of bladder injuries are detected using this technique.
If the CT shows a renal laceration or hematoma, the patient should be admitted and managed according to your solid organ injury protocol. Kidney injuries fare better that livers and spleens, and only rarely require surgery. If no kidney or bladder injury is seen, the default diagnosis of a renal contusion is the culprit. No treatment is needed, and the patient can be discharged if no other injuries are present. The blood will clear over a few days, but may disappear and reappear a few times in the process. The patient can followup with their primary care physician in a week or two.
An interesting trauma ethics question today.
A Connecticut driver was charged with manslaughter last year after striking a 14 year old bicyclist and killing him. The driver, who is serving a 10 year sentence for manslaughter, is now suing the family for putting him there.
According to the prosecutor, the driver was passing another vehicle at 83 mph in a 45 mph zone. The teen was with friends who were jumping bikes at the curb of a busy street. He entered the street and was struck, sustaining multiple severe injuries and was brain dead the next day.
The driver is suing the parents for “contributory negligence” because had they “complied with the responsibilities of a parent and guardian and the laws of this state and not allowed their son to ride his bicycle without a helmet and to play out in the middle of Rt. 69 … this incident and Matthew’s death would not have happened.” He’s also asking for more than $15,000 in damages, saying he’s endured “great mental and emotional pain and suffering,” wrongful conviction and imprisonment, and the loss of his “capacity to carry on in life’s activities.”
On one hand, what is the responsibility of the teen and his family, or anyone for that matter, for taking reasonable precautions to be safe? On the other, no pedestrian, bicyclist or motorcyclist can survive an impact with a car traveling at 83 mph.
One attorney commented on the case, saying "I can see their side of it. I’m a parent. But I can also see the other side of it. If you’re driving down the street and your car makes contact with a pedestrian and you think it’s the pedestrian’s fault, you have to raise the issue.“
Interesting scenario? Read the full story and tell me who you think is right, and why?