Compliance With Bladder Injury Guidelines

Management of bladder injury seems straightforward. For many years, the gold standard was the cystogram. But for best results, this study had to be done a certain way. This included bladder instillation, imaging in two planes (AP and lateral), and a post-void view.

As CT scan use became more prevalent, we discovered that diagnosis of bladder injury became even more accurate. However, we also soon discovered that even though the pictures looked very good, some bladder injuries were being missed. It turns out that allowing passive filling of the bladder by clamping the urinary catheter (or not inserting one) missed upwards of 50% of injuries.

So the standard became the “CT cysto” technique. It is performed similar to a non-CT cystogram, by infusing contrast into the bladder under pressure. With this modification, the accuracy of the study approaches 100%. But do we all do it this way? No!

A study from the University of Utah reviewed registry data from all Utah Level I trauma centers over a 15 year period. A total of 124 patients with bladder injuries were identified. Interesting results include:

  • Extraperitoneal rupture was more common (60%) than intraperitoneal (31%) or both (9%)
  • Conventional CT was used in 56%, and cysto or CT cysto in 24%. The remainder were found in OR.
  • Initial imaging missed or incorrectly diagnosed this injury in 13% of patients! Nine of these used the wrong study (conventional CT), but 4 of these missed occurred using the recommended one.
  • Overall compliance with using the recommended study was only 44%

Bottom line: Compliance in this 15 year study was low. Unfortunately, they lumped conventional cystogram with CT cysto. These days, fewer conventional studies are performed and the error rate may be higher. However, current day compliance is still low in my experience. A bladder evaluation guideline should be developed and disseminated to emergency physicians, surgeons and radiologists (see the CT cysto link below). This is the only way we’ll be able to decrease the number of missed injuries for this problem.

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Reference: Process improvement in trauma: traumatic bladder injuries and compliance with recommended imaging. J Trauma 74(1):264-269, 2013.

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