Tag Archives: blunt trauma

General

Evaluation of Hematuria in Blunt Trauma

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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.

General

Syncope Workup in Trauma Patients

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Syncope accounts for 1-2% of all ED visits, and is a factor in some patients with blunt trauma, especially the elderly. If syncope is suspected, a “syncope workup” is frequently ordered. Just what this consists of is poorly defined. Even less understood is how useful the syncope workup really is.

Researchers at Yale retrospectively looked at their experience doing syncope workups in trauma patients. They were interested in seeing what was typically ordered, if it was clinically useful, and if it impacted length of stay. 

A total of 14% of trauma patients had syncope as a possible contributor to their injury. The investigators found that the following tests were typically ordered in these patients:

  • Carotid ultrasound (96%)
  • 2D Echo (96%)
  • Cardiac enzymes (81%)
  • Cardiology consult (23%)
  • Neurology consult (11%)
  • EEG (7%)
  • MRI (6%)

Most of this testing was normal. About 3% of cardiac enzymes were abnormal, as were 5% of carotid imaging and 4% of echocardiograms. 

Important! Of the patients who underwent an intervention after workup, 69% could have been identified based on history, physical exam, or EKG and did not depend on any of the other diagnostic tests.

Conclusion: Syncope workup is not needed routinely in trauma patients with syncope as a contributing factor. Need for intervention can usually be determined by history, exam and EKG performed in the ED. In this study, $216,000 in excess costs would have been saved!

Reference: Routine / protocol evaluation of trauma patients with suspected syncope is unnecessary. Davis, et al, Yale University. Presented at the 23rd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma, January 2010.

General

Trauma 20 Years Ago: Blunt Aortic Injury in Children

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We always worry about the aorta after high-energy blunt trauma in adults. Should we be doing the same in kids? After all, they are very elastic and for the most part they are tough to break.

A 13 year review was undertaken by the CV surgeons at Harborview twenty years ago which tried to answer this question. They looked at medical examiner records of all pediatric deaths (16 or younger) and identified the ones with traumatic aortic injury. They found only 12 deaths (2.1%), and somehow they also tracked one survivor (from ME data???). The age range was 3-15, with a mean of 12 (which means that the majority were in the older age group).

Six children were pedestrian struck, 5 were involved in car crashes, and two were on motorized bikes or ATVs. None of the children in car crashes were restrained and two were ejected. Four of the five were traveling > 55mph. All had other serious injuries, including abdominal and orthopedic.

It’s tough to draw any meaningful conclusions from this paper due to the small numbers, the retrospective design, and the lack of a denominator. The only thing it does tell us is that aortic injury is bad, and that kids should not get hit by cars and should wear their seat belts. The mean age suggests that it involves primarily older children. But we kind of knew all that already.

What it does not help with is figuring out at what age we need to start thinking about imaging the aorta with CT scan. I’ll be digging into that a little more this week.

Reference: Eddy et al. The epidemiology of traumatic rupture of the aorta in children: a 13 year review. J Trauma 30(8): 989-992, 1990.

General

Initial Management of Blunt Bladder Injury

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Bladder injury is uncommon after blunt trauma. It is typically seen after high energy events, most commonly a motor vehicle crash with a lap belt in place. During the initial evaluation, the patient may complain of abdominal pain, but this is not universal. 

FAST results are also inconsistent. Free fluid may be seen, and an irregular bladder outline may also be appreciated. The key to diagnosis is placement of a urinary catheter. Bloody urine is found nearly 100% of the time. 

The character of the bloody urine suggests what type of injury is present. Faint hematuria, primarily shades of pink, is usually associated with renal injury or a bladder contusion. A moderate amount of darkly bloody urine is frequently associated with extraperitoneal bladder injury. A small amount of very dark, bloody urine may mean an intraperitoneal bladder injury. Finally, scant and very dark blood in the catheter suggests a urethral injury or a catheter balloon inflated in the urethra.

Examination of the urine is suggestive but not diagnostic of the type of injury. Determining the real diagnosis requires imaging, and evaluation of the entire GU tract is essential. CT scan is used to evaluate the kidneys, ureters, and to some degree, the bladder. Cystogram is required to fully evaluate the bladder, and a CT technique may be used. Bladder imaging using passive filling by clamping the catheter is accurate only 50% of the time. The bladder must be pressurized using contrast instilled into the bladder by gravity. When performed in this manner, the CT cystogram is 97% accurate.

Once a diagnosis of bladder injury is made, the treatment is usually straightforward. Extraperitoneal injuries usually do not require repair and will heal on their own. However, if the symphysis pubis needs instrumentation to restore anatomic position, concomitant repair of the bladder is frequently necessary to keep the hardware from being contaminated by urine. 

Intraperitoneal injuries require operative repair. If possible, the injured area should be opened and the inside visually inspected. If the injury extends anywhere near the trigone, a urology consult should be obtained. Most repairs are simple two layer closures. The mucosal layer must be made with absorbable suture; the outer layer is surgeon’s choice. 

For either type of bladder injury, the urinary catheter should be left in place for about 10 days. A cystogram should be obtained, and in most cases there will not be any leakage of urine and the catheter can be removed. In the event of a leak, another 7 days with the catheter is in order and the cystogram can be repeated.

The vast majority of bladder injuries can be easily handled by the trauma surgeon and are healed completely within two weeks.

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