IMMEDIATE MANAGEMENT OF LIFE-THREATENING INJURIES
Genitourinary injuries occur in 10–20% of major trauma patients. Most of these injuries, with the exception of renal hilar disruption or shattered kidney, are not immediately life threatening.
Because they are often accompanied by potentially life-threatening injuries to other organ systems, it is easy for the emergency physician to overlook and therefore miss signs or symptoms of urologic injury. Failure to diagnose and treat these injuries properly can result in significant long-term morbidity. Therefore, while evaluating the trauma patient, the physician needs to be aware of clues to genitourinary injury. These clues include (1) lumbar vertebral or lower rib fractures, (2) pelvic fractures, (3) flank pain or hematoma, (4) abnormal prostate (high riding, nonpalpable, or free floating) on rectal examination, (5) blood at the urethral meatus, and (6) gross hematuria.
For all patients with blunt or penetrating trauma, evaluate airway, breathing, circulation, and disability during the primary survey as per advanced trauma life support protocol (Chapter 12). During the secondary survey, evaluate for a boggy or high-riding prostate on rectal examination, perineal or scrotal hematoma, and any evidence of blood at the urethral meatus. If any of these signs is present, perform a retrograde urethrogram (RUG) before inserting a Foley catheter. If the signs are absent, insert a Foley catheter if indicated (ie, in unstable patients or those unable to urinate). Urethral studies should never delay diagnostic studies of, or treatment for, potentially life-threatening injuries. Figures 26–1, 26–2, 26–3 provide algorithms for managing blunt, penetrating, and pediatric urologic injury.
Algorithm for staging blunt trauma in the adult. CT, computed tomography; RBC/HPF, red blood cells per high-power field; SBP, systolic blood pressure. (Modified with permission from Tanagho EA, McAninch JW: Smith’s General Urology, 13th edition. New York: Appleton & Lange; 1992.)
Algorithm for staging penetrating trauma in the adult. (Modified with permission from Tanagho EA, McAninch JW: Smith’s General Urology, 13th edition. New York: Appleton & Lange; 1992.)
Algorithm for the evaluation of blunt trauma in children. CT Abd, computed tomography of the abdomen; IV, intravenous; RBC/HPF, red blood cells per high-power field. (Modified with permission from Tanagho EA, McAninch JW: Smith’s General Urology, 13th edition. New York: Appleton & Lange; 1992.)
Special Examinations and Procedures
Because of the need to determine if Foley catheter placement is safe, evaluation of the genitourinary system is generally performed in a retrograde fashion: rule out urethral injury before bladder (usually by physical examination), then bladder (by placing a Foley catheter) before ureteral or renal injury.