Trauma and Critical Care—GU Trauma
Concept
Will usually be couched in another question, for example, the multiple injured trauma patient who has a retroperi- toneal hematoma seen after exploration of a penetrating abdominal injury. Could also be seen in the setting of blunt trauma with a pelvic fracture. Don’t forget the pri- orities in trauma patients . . . ABCs.
Way Question May be Asked?
“19 y/o male seen in the emergency room after a GSW to his right flank with a SBP of 90 and gross hematuria after placement of a foley catheter. What do you want to do?”
Could also have presentation after a fall from a height or a car accident with a pelvic fracture secondary to blunt trauma. Make decision on stability of the patient early and frequently reassess throughout the scenario.
How to Answer?
ABCs
Primary Survey Secondary Survey
History
AMPLE history (Mechanism of injury, . . .) Pre-existing renal disease
Physical Exam
Full exam in secondary survey especially Blood at urethral meatus
Stool guiac for possible rectal injury
“High riding” prostate in male
How to Answer?
Need complete labs, CXR, U/A (hematuria)
DPL in unstable pts (this is a common Oral Exam theme!)
CT scan in stable pts with IV contrast (evaluate both kidneys)
Retrograde cystourethrogram to define urethral injury
Surgical Treatment
Be sure to r/o other intra/extraabdominal injuries:
(1) Bladder injuries
(a) extraperitoneal female—Foley catheter or suprapubic cystostomy
(b) extraperitoneal male—suprapubic cystostomy (c) intraperitoneal—primary repair and suprapu-
bic cystostomy
(2) Ureteral injuries—key is the level of injury (a) lower third—ureterneocystostomy +/− psoas
hitch
(b) middle third—end to side ureteroureterostomy to other ureter (most urologists hate this option) (c) proximal third—nephrostomy tube in ipsilat-
eral kidney
(d) if tissue loss minimal, can try primary repair over a stent
ALWAYS drain site of repair!
(3) Renal parenchymal injury
(a) non-visualization on CT/IVP→ angiography and/or exploration promptly (1 h warm ischemia time too much!)
(b) renal vein injury→repair in stable pts, otherwise ligate
(c) renal artery→repair in stable pts otherwise nephrectomy
(d) extravasation→repair or partial resection in stable pt otherwise nephrectomy
(e) pedicle avulsion→nephrectomy 132
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(4) Retroperitoneal hemotomas
(a) all hematomas in penetrating trauma should be explored unless subhepatic
(b) can observe hematoma in blunt trauma as long as not expanding
(c) should explore central, portal, and pericolonic hematomas
(5) Urethral injuries whether partial or total, gets cys- tostomy and delayed urethroplasty
(6) To expose retroperitoneal structures Mattox maneuver on left
Cattell maneuver on right
Common Curveballs
Pt will be unstable
Will have intra-op retroperitoneal hematoma Will have one kidney
Will have bladder injury, first extraperitoneal, then intraperitoneal
Will have ureteral injury in a variety of locations Post-op hypertension from activation of renin/
angiotensin/aldosterone axis
Post-op extravasation of contrast from bladder/kidney injury
Asked when you will perform a nephrectomy
There will be injury to other retroperitoneal organs (duodenum, pancreas, colon)
Will be asked to describe performing psoas hitch or nephrostomy tube placement
Strikeouts
Any sort of laparoscopic treatment/evaluation
Getting stuck on therapeutic embolization for renal laceration
Not checking meatus/rectum in pelvic fracture pt Not exploring retroperitoneal hematoma when appro-
priate
Not performing nephrectomy when appropriate Not ruling out other, more life-threatening injuries Not looking for injuries to other retroperitoneal organs Performing CT scan in unstable pt
Strikeouts 133
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