All posts by TheTraumaPro

4 Guidelines For the Management Of Bladder Injury

The Eastern Association for the Surgery of Trauma (EAST) has been at the forefront of trauma practice guideline dissemination for decades. They recently published a set of recommendations for managing patients with bladder injury. These injuries are not commonly encountered by trauma professionals, and I thought a refresher on current thinking on their management was in order.

Using the usual methodology, the trauma literature was scanned for papers dealing with this topic. After screening for quality, the field was narrowed to 17 papers which were used to formulate the published recommendations. These cover imaging and management questions that frequently come up during the evaluation of these patients.

Following are the questions raised, the EAST recommendations, and my commentary about them:

    • In patients with abdominal / pelvic trauma, should retrograde CT cystography vs no imaging be used to diagnose a bladder injury? This seems like a silly question, but the answer lies in the details. It all boils down to the likelihood of injury. And how does one determine likelihood? By looking at the urine and the fracture patterns around the bladder. Patients with microscopic hematuria are very unlikely to have a bladder injury, and any type of bladder imaging in these patients (cystogram, CT cystogram) is almost never positive, and so is not indicated. This is the reason that ordering a urinalysis in major trauma patients is not recommended. However, if gross hematuria is present, CT cystogram is recommended. The sensitivity and specificity are nearly perfect. Just be sure to do a true cystogram by actively filling the bladder with contrast via a urinary catheter. Passive filling of the bladder with urine from the IV contrast misses about half of all the injuries. Also, strongly consider adding CT cystogram in patients with widening of the pubic symphysis. This injury pattern is frequently associated with bladder injury.
    • In patients with intraperitoneal bladder rupture from blunt trauma, should operative or nonoperative management be used to decrease complications? Another silly question? In general, intraperitoneal bladder ruptures do not heal on their own, so urine continues to bathe the peritoneal cavity until the injury is fixed. The review article recommended that operative repair be performed in all of these cases. 
    • In patients with extraperitoneal bladder rupture from blunt trauma, should operative or nonoperative management be used to decrease complications? Patients with a simple extraperitoneal bladder injury should undergo nonoperative management. These injuries usually heal and seal within about 10 days. However, patients with this type of bladder injury that is more complicated (bone spicules piercing the bladder, concomitant vaginal or rectal injury, bladder neck injury) should undergo operative repair in order to decrease the complication rate. One additional group that should be repaired: patients with pubic diastasis that will require operative fixation. The bladder should be repaired at the time of the orthopedic procedure to avoid bathing the new hardware in urine.
    • In patients who have undergone operative or nonoperative management of bladder injury, should bladder closure be assessed with cystogram or not? This one depends on the type and complexity of injury. For simple intraperitoneal bladder injuries that were operatively repaired, no followup cystogram is required. More complex repairs should be evaluated by cystogram before removing the urinary catheter. Finally, simple extraperitoneal injuries should also have a cystogram obtained before removing the catheter. My magic number for obtaining followup studies is 10 days. There is no real science behind this, and no one has systematically looked at 5 vs 7 vs 10 vs 14 days. This one is based only on personal experience.

And by the way, most simple bladder injuries (both intra- and extra-peritoneal) can be easily repaired using two layers by your friendly neighborhood trauma surgeon. More complex injuries are generally best left to the urologist.

Reference: Management of blunt force bladder injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma 86(2):326-336, 2019.

Coming Soon! New Site For Trauma PI!

One of the most common requests I get is to provide more detailed content on Trauma Performance Improvement! To that end I am putting together a collection of print and video content on a new website that will address the things you really want to hear about but can’t find anywhere else.

Here’s a sample listing of some of the topics that will be covered:

  • Writing a good PI plan
  • Loop closure – basic to advanced
  • Involving your TMD
  • PRQ preparation
  • Creating workable practice guidelines
  • Crafting a Massive Transfusion Protocol that works for you
  • How to calculate your optimal number of trauma registrars
  • Preparing for your site survey
  • How to read your TQIP report
  • What is OPPE and how do I do it?
  • Integrating PI with your registry
  • How to interpret the Orange Book

If you want to be one of the first to get access to this content, please fill out the form by clicking here. Your name will be placed on my early bird e-mail list. I’ll provide regular updates on the opening date, and solicit your ideas on specific content you would like to see.

Subscribe to the mailing list now!

Air Embolism From an Intraosseous (IO) Line

Intraosseous (IO) lines are a godsend when we are faced with a patient who desperately needs access but has no veins. The tibia is generally easy to locate and the landmarks for insertion are straightforward. They are so easy to insert and use, we sometimes “set it and forget it”, in the words of infomercial guru Ron Popeil.

But complications are possible. The most common is an insertion “miss”, where the fluid then infuses into the knee joint or soft tissues of the leg. Problems can also arise when the tibia is fractured, leading to leakage into the soft tissues. Infection is extremely rare.

This photo shows the inferior vena cava of a patient with bilateral IO line insertions (black bubble at the top of the round IVC).

During transport, one line was inadvertently disconnected and probably entrained some air. There was no adverse clinical effect, but if the problem is not recognized and the line is not closed properly, there could be.

Bottom line: Treat an IO line as carefully as you would a regular IV. You can give anything through it that can be given via a regular IV: crystalloid, blood, drugs. And even air, so be careful!

Giving TXA Via An Intraosseous Line?

Seriously injured patients frequently develop coagulopathy, which makes resuscitation (and survival) more challenging. A few years ago, the CRASH-2 study lent support for using tranexamic acid (TXA) in select trauma patients to improve survival. This drug is cheap and has antifibrinolytic properties that may be beneficial if given for life-threatening bleeding within 3 hours of initial injury. It’s typically given as a rapid IV infusion, followed by a slower followup infusion. The US military has adopted its routine use at forward combat hospitals.

But what if you don’t have IV access? This can and does occur with military type injuries. Surgeons at Madigan Army Medical Center in Washington state tried using a common alternative access device, the intraosseous needle, to see if the results were equivalent. This study used an adult swine model with hemorrhage and aortic crossclamping to simulate military injury and resuscitation. Half of the animals then received IV TXA, the other half had it administered via IO. Only the bolus dose was given. Serum TXA levels were monitored, and serial ROTEM determinations were performed to evaluate coagulopathy.

Here are the factoids:

  • The serum TXA peak and taper curves were similar. The IV peak was higher than IO and approached statistical significance (0.053)
  • ROTEM showed that the animals were significantly hyperfibrinolytic after injury, but rapidly corrected after administration of TXA. Results were the same for both IV and IO groups.

Bottom line: This was a very simple and elegant study. The usual animal study issues come into play (small numbers, pigs are not people). But it would be nearly impossible to have such a study approved in humans. Even though the peak TXA concentration via IO is (nearly significantly) lower, this doesn’t appear to matter. The anti-fibrinolytic effect was very similar according to ROTEM analysis.

From a practical standpoint, I’m not recommending that we start giving TXA via IO in civilian practice. We don’t typically see military style injuries, and are usually able to establish some type of IV access within a reasonably short period of time. But for our military colleagues, this could be a very valuable tool!

Reference: No intravenous access, no problem: Intraosseous administration of tranexamic acid is as effective as intravenous in a porcine hemorrhage model. J Trauma 84(2):379-385, 2018.

4 Good Lab Values From Intraosseous Blood – And Some Not So Good Ones Too

The intraosseous access device (IO) has been a lifesaver by providing vascular access in patients who are difficult IV sticks. In some cases, it is even difficult to draw blood in these patients by a direct venipuncture. So is it okay to send IO blood to the lab for analysis during a trauma resuscitation?

A study using 10 volunteers was published last year (imagine volunteering to have an IO needle placed)! All IO devices were inserted in the proximal humerus. Here is a summary of the results comparing IO and IV blood:

  • Hemoglobin / hematocrit – good correlation
  • White blood cell count – no correlation
  • Platelet count – no correlation
  • Sodium – no correlation but within 5% of IV value
  • Potassium – no correlation
  • Choloride – good correlation
  • Serum CO2 – no correlation
  • Calcium – no correlation but within 10% of IV value
  • Glucose – good correlation
  • BUN / Creatinine – good correlation

Bottom line: Intraosseous blood can be used if blood from arterial or venous puncture is not available. Discarding the first 2cc of marrow aspirated improves the accuracy of the lab results obtained. The important tests (hemoglobin/hematocrit, glucose) are reasonably accurate, as are Na, Cl, BUN, and creatinine. The use of IO blood for type and cross is not yet widely accepted by blood banks, but can be used until other blood is available. NOTE: your lab may try to refuse the specimen due to “other stuff” (marrow) in the specimen. Have them run it anyway!

Reference: A new study of intraosseous blood for laboratory analysis. Arch Path Lab Med 134(9):1253-1260, 2010.