The quiz presented a single slice from a pelvic CT, asking for mechanism, age and diagnosis.
So here’s how to do it. First, what’s wrong in the picture? A number of you picked this one out. The right buttock area has a large hematoma present, and there is a contrast blush posteriorly. This is an injury to the gluteal artery with active extravasation.
Next, look at the rest of the image. Not a whole lot to see, but there is significant calcification of pelvic arteries. So this patient is elderly.
Finally, what happened? Elderly people who have gluteal artery injuries are typically pedestrians struck by a car. Most other blunt mechanisms don’t have enough energy to do this.
And what about treatment? Sometimes in younger patients, the bleeding will stop, but don’t count on it. And in the elderly, it almost never does. Angioembolization is the best way to treat this problem, because surgical exploration is generally a bloody mess.
Piece of cake! Congrats to the readers who got this one right!
Great questions, and I’d love to answer in detail. Please contact me by email (see my profile at the side of the page) so we can chat!
So far, no correct answers to all three questions from yesterday’s pop quiz! Given the scan below, I want to see if you can figure out:
- Mechanism of injury
- Age range
And bonus points for the correct answer on how to treat the problem!
Hint: You can tell the age by the appearance of the blood vessels in the pelvis. And the bright areas outside the pelvis may not be calcium. This should give you enough information to figure out the rest.
Tweet or comment your results!
Here’s a typical barebones clinical problem for you:
Given the usual statistical probabilities, tell me these three things:
- Mechanism of injury
- Age range
Please tweet to @RegionsTrauma or leave comments with your answers! More info tomorrow!
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!
Reference: CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. Am J Roentgenol 187(5):1296-302, 2006.
Intraperitoneal bladder rupture
Extraperitoneal bladder injury