Abdominal and Genitourinary Trauma

1
Abdominal and Genitourinary Trauma

• Steve Lan
• September 25, 2003

2
Abdominal Trauma

• Anatomy
• History/Examination
• Investigations
• Blunt Trauma
• Penetrating Trauma

3
Principles

• Two questions
• Who needs an OR?
• How fast do they need it?
• Focus of history, physical exam and
  investigations

4
Ouch
5
Anatomy
6
Anatomy
7
Anatomy
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History

• ABCDEs
• Often limited but focus on mechanism
• Blunt vs penetrating
• Associated injuries
• Radiation of pain
• Scapula irritation of hemidiaphragm
• Testicle irritation of retroperitoneum

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Physical

• Vitals
• Soft/rigid/distension, bowel sounds
• Turners (flank bruising), Cullens (bruising
  around umbilicus) takes 12h several days to
  show
• Entry/exit wounds
• Rectal
• Serial exams

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Case 1

• 30 yo male, PMHx 0
• MVA - Head on collision, 60 km/h
• No air bags, lap belt
• What type of abdo injury is this?

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Abdominal TraumaBlunt
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Blunt Abdominal Trauma

• Greater mortality than penetrating
• Occult injuries and associated with other trauma
• Difficult to assess
• ?history
• Altered LOC
• Other injuries
• Etc.

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Blunt Abdominal TraumaPathophysiology

• Sudden increase in pressure rupture or burst
  within hollow viscus
• Compression of visera from anterior force and
  posterior vertebral body crush injury
• Shearing of organs and vascular pedicles to tear

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Blunt Abdominal TraumaPathophysiology

• Seatbelt injury
• 3 point better than lap belt
• Compression of bowel between belt and vertebral
  column
• Spectrum of presentation
• mild symptoms to hemoperitoneum
• Seatbelt sign
• Contusion across lower abdo
• Specific but poor sensitivity (lt33)

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Blunt Abdominal Trauma

• Incidence of organ injury

Spleen 40.6
Liver 18.9
Retroperitoneum 9.3
Small Bowel 7.2
Kidneys 6.3
Bladder 5.7
Colorectal 3.5
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Case 1 continues

• BP 124/60, HR 95, RR 14, Sats 94 on 3L
• Intubated for GCS of 9, pt in collar
• Abdo exam
• Mild abrasion to LUQ/flank
• No Cullens or Gray-Turners Mild distension,
  decreased bowel sounds
• Does he need a rectal?

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Fingers and tubes in every orifice
The only reason not to do a rectal, is if there
is no rectum or if you dont have a finger
Hmmm???
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DRE in Trauma?

• Rosens yes, to look for gross blood, sub-Q
  emphysema
• Prospective observational study, Level II trauma
  center
• 432 pts
• 99 normal prostate, 5.2
• FOB (no change in Rx),
• 0.7 gross blood (penetrating injury),
• tone normal in 96, decreased in 4

Porter, J. Ursic, C. Digital Rectal Examination
for Trauma Does Every Patient Need One? The
American Surgeon. 2001 5 438-441.
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DRE in Trauma?

• Changed management in 1.2 (5 cases)
• Suggest DRE in
• Penetrating injury
• ?spinal cord injury
• severe pelvic

Porter, J. Ursic, C. Digital Rectal Examination
for Trauma Does Every Patient Need One? The
American Surgeon. 2001 5 438-441.
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Case 1 laparotomy?

• Clinically (Rosens)
• Unexplained hypotension
• Peritoneal irritation
• Radiologic evidence of pneumoperitoneum
• Evidence of diaphragm rupture
• Persistent GI bleed (NG, vomit, rectal)

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Case 1 Further Investigations

• What labs do you want doctor?

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Abdominal TraumaInvestigations Labs

• Most not too helpful acutely
• Lipase/amylase cant rule in/out pancreatic
  injury
• Same with LFTs
• What about in pediatric trauma?

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Case 1 - Radiology

• FAST or CT abdo? (DPL not used here in Calgary)

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Abdominal TraumaComparison of Investigations

• Comparison in CAEP

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Abdominal TraumaInvestigations FAST

• Free fluid after blunt trauma
• perihepatic and hepatorenal space (Morrisons
  pouch)
• perisplenic
• pelvis (Pouch of Douglas)
• pericardium
• Does not look at solid organs, retroperitoneum,
  diaphragm

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Abdominal Trauma

• FAST exam of pelvis

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Abdominal TraumaFAST Algorithm
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Abdominal TraumaFAST Algorithm
CAEP 1(2), 1999.
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Case 1 Continued

• No blood on U/S but
• Pt stable since first fluid bolus
• CT ordered
• Oral contrast do you need it?? (Rosens- CT has
  low sensitivity for injury to small bowel,
  mesentary, pancreas)
• Is it safe??

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CT /- Oral Contrast

• RCT, 500 pts _at_ level I trauma centre
• Abnormal scans equal between groups
• One unnecessary lap in each group
• One missed SB injury with OC (sensitivity 86),
  none missed in non OC group
• No difference in sensitivity for solid organ
  injury (84 vs 88)
• Conclusion oral contrast only slows CT for blunt
  abdo trauma

Stafford, et al. Oral contrast solution and CT
for blunt abdominal trauma. Arch Surg. 1999 134
(6) 622-6.
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Safety of Oral Contrast

• Retrospective review
• 506 pts either drank contrast or had ETT and
  contrast via NG
• No aspiration of contrast (except for pt with NG
  into R bronchus!)

Federle, et al. Use of oral contrast material in
abdominal trauma CT scans Is it dangerous?
Journal of Trauma. 1995 38(1) 51-55.
32
Oral Contrast and kids

• Retrospective review of 101 children with blunt
  trauma
• 60 pts received contrast
• 37 (62) duodenum not opacified after 30 min
• Intestinal injuries found on laparotomy did not
  correlate to CT findings with/without oral
  contrast

Shankar, et al. Oral contrast with CT in the
evaluation of blunt abdominal trauma in children.
BJSurg. 1999 86(8) 1073-7.
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Abdo TraumaPediatrics

• 85 blunt MVA, pedestrian vs car, fall out of
  car, child abuse
• Watch for coagulopathies
• Poor musculature and less AP diameter increase
  risk of compression with blunt force
• Difficulties include communication, fear,
  aerophagia (decompression may help ventilation
  and exam)

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Abdo Trauma in Kids

• Prospective observational study
• lt 16yo (8.4/-4.8 yrs), blunt trauma, at level I
  trauma center
• 1095 pts, 107 (10) with intra-abdo injury

Finding Odds Ratio Confidence
Hypotension 4.1 1.1-15.2
Abdo tenderness 5.8 3.2-10.4
AST gt200 17.47 9.4-32.1
gt5 RBC/HPF 4.8 2.7-8.4
Holmes, JF. Identification of children with
intra-abdominal injuries after blunt trauma. Ann
Emerg Med. 2002 39(5) 500-9
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Case 2

• 22 yo male presents with stab wound to abdomen
• BP 155/90, HR 90, mentating well
• What historical features are important?

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Stab Wounds

• Most stab wounds dont cause intraperitoneal
  injury
• Instrument (size, still in one piece)
• stabs
• posture of patient

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Stab Wounds

• 3 Qs
• Urgent laparotomy?
• Peritoneum violation
• If peritoneum violated laparotomy?
• Clinical indications (Rosens) hemodynamic
  instability, peritoneal signs, evisceration,
  diaphragmatic injury, GI bleed,
  implement-in-situ, intraperitoneal air

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Case 2 do you want to explore the wound?

• Shave and prep, local anesthetic
• Extend wound and visualize layers
• Do not blindly probe
• Advocated for anterior abdo wounds, but all else
  ??
• Watch thoracolumbar junction

Markovchick. Local wound exploration of anterior
abdominal stab wounds. J of Emerg Med. 1985 2(4)
287-91.
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Penetrating Trauma

• Anterior abdomen
• Ant axillary line, costal margins, groin crease
• Flank
• Ant/post axillary line, inf scapula to iliac
  crest
• Back
• Post axillary line, inf scapula to iliac crest

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Case 2 continued

• LWE confident that knife did not penetrate the
  peritoneum
• Is it reasonable to stitch him up and d/c from
  the ED?

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Selective Management

• Retrospective review of 455 with penetrating
  truncal injuries (Detroit)
• 194 directly to OR
• 107 had selective w/u (triple contrast CT, LWE,
  observation)
• 136 d/c home after hx, px, plain films
• Missed 2 injuries w/o significant consequence
• Conclusion stable pts with negative selective
  w/u can be d/cd home

Conrad, et al. Selective management of
penetrating truncal injuries. Am Surg. 2003
69(3) 266-72.
44
Case 2

• No free air on upright CXR, how sensitive is
  this?
• 13 pts with abdominal trauma (blunt and
  penetrating)
• Upright CXR sensitivity from 0 if less than 3
  pockets of 1mm of air, to 100 if pocket of air gt
  13mm

Stapakis. Diagnosis of pneumoperitoneum
abdominal CT vs upright chest film. J of Comp
Assist Tomo. 1992 16(5) 713-6.
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GSW
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Penetrating TraumaGSW

• Ek 1/2mv2
• E directly proportional to amount of injury
• Other factors resistance of tissue, stability
  of missle, impact velocity
• Diagnostics and considerations similar to stabs

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Penetrating Trauma and CT

• Prospective study, 104 pts with penetrating
  trauma (54 GSW, 50 Stab)
• Triple contrast (oral/rectal/IV) helical CT
• No indication for immediate lap
• Positive CT peritoneal violation, injury to
  retroperitoneal colon, major vessel, urinary
  tract
• CT 100 sensitive, 96 specific, 100 NPV, 97
  accuracy in predicting need for lap

Shanmuganathan, et al. Triple-contrast helical CT
in penetrating torso trauma. Am J Roen. 2001
1771247-56.
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Genitourinary Trauma

• 10 of trauma has GU involvement (USA)
• Lower Tract Bladder and urethra
• Upper Tract renal and ureter
• External genitalia

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Genitourinary Trauma

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Genitourinary Trauma
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Genitourinary Trauma
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Pelvic Trauma(Campbells Urology, 2002)

• Main issues
• urethral injury? If so, no cath
• bladder rupture? intraperitoneal needs repair
• renal injuries?

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Genitourinary TraumaInitial Assessment

• Pelvic stability, suprapubic/pubic tenderness
• Bruising/hematoma to penile shaft, scrotal skin,
  perineum
• Blood at meatus
• PV blood, lacerations in vault
• Rectal exam Blood, high riding prostate

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Urethral Trauma

• Prostatic urethra is contiguous with urogenital
  diaphragm
• Held in place by ligaments
• Pelvic with displacement of symphysis lacerates
  prostatic urethra

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Urethral Trauma

• Importance
• Acutely missed may convert partial to complete,
  difficult to assess urine output
• Long term strictures, incontinence

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Urethral Trauma

• Classic Triad (Campbells Urology, 2002)
• Blood at meatus, inability to void, palpable full
  bladder
• Blood sensitivity 50 (J Urol 1988140506507)
• High riding prostate sensitivity only 34, poor
  specificity (Br J Urol 199677876880)
• No study combining factors
• Proximal injury pelvic (4-14)
• Distal injury straddle, instrumentation, GSW

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Urethral Trauma
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Urethral TraumaManagement

• Retrograde urethrogram
• If some contrast into bladder, may try one pass
  of Foley (Rosens)
• may pass in partial tear
• 10 associated with bladder rupture

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Retrograde Urethrogram For Dummies

• Patient may be supine for study
• Oblique films may help
• Pre-injection KUB
• X-mas tree adaptor
• /- inflation of Foley balloon proximal to fossa
  navicularis (may leak contrast around penis)

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Retrograde Urethrogram
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Retrograde Urethrogram

• 60 cc of full-strength or half strength contrast
  injected over 30-60 sec
• Repeat x-ray during last 10 cc of contrast

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Retrograde Urethrogram
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Bladder Trauma

• Rare lt2 of trauma
• Generally associated with major injuries
• When present mortality 12-22

Carroll PR, McAninch JW Major bladder trauma
Mechanisms of injury and a unified method of
diagnosis and repair. J Urol 1984132254257.
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Who needs imaging?

• Review of indications for imaging
• Blunt trauma, ?bladder injury
• CT cysto if need abdo/pelvis imaging, if not use
  cystogram

Morey, et al. Bladder Rupture after blunt trauma.
J Trauma. 2001 51(4) 683-686.
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Bladder TraumaCystography
Extraperitoneal
Intraperitoneal
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CT Cystography

• Retrospective review 316 pt with blunt trauma
  that received CT cysto
• Radiology interpretation compared to OR report
• Detection of bladder rupture sensitivity 95,
  specificity 100

Deck, et al. Current experience with CT
cystography and blunt trauma. W J Surg. 2001
25(12) 1592-6.
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Bladder TraumaManagement

• Contusions (67 of injuries)
• Hematuria w/o evidence of injury on imaging
• Conservative
• Intraperitoneal (usually burst injury)
• Requires OR (non urgently)

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Bladder TraumaManagement

• Extraperitoneal (penetrating or blunt)
• Some controversy
• Bladder drainage (J Urol 1983129946948)
• Exceptions bone fragment, open , lap for other
  reasons

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Renal Trauma

• As always The main question is who needs
  imaging??
• History and Physical
• Urinalysis

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Case Example

• 26 yo Male
• Punched in the kidneys, yesterday
• VSS, mild R flank bruising, no associated
  injuries
• Nurse notes urine dipped positive for blood
• Does this patient need further imaging?

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Renal TraumaAnatomy
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Renal Trauma- History

• More often injured in children as kidneys are
  relatively larger
• Blunt vs Penetrating
• Blunt
• Fall, MVA, assault
• Key info deceleration (pedicle avulsion)
• Penetrating
• Stab, GSW

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Renal TraumaUrinalysis

• Degree of hematuria doesnt correlate with degree
  of damage
• 36 of renovasc injuries dont have hematuria

Cass AS Renovascular injuries from external
trauma. Urol Clin North Am 198916213220
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Adults and Hematuria

• 1484 pts with blunt abdo trauma
• Gross hematuria - 65 had significant
  intra-abdominal injury
• Microscopic hematuria shock - 29 had
  significant injury
• No pts with hematuria and normotensive had
  significant injury
• Imaging for these pts

Knudson, MM, et al. Hematuria as a predictor of
abdominal injury after blunt trauma. Am J Sug.
1992 164(5) 482-6.
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Microscopic Hematuria

• Review article looking at evidence for imaging in
  blunt trauma with microscopic hematuria
• Imaging only indicated if hypotensive or have
  associated injuries

Saunders F, Argall J. Investigating microscopic
hematuria in blunt abdominal trauma. Emerg Med
Journal. 2002 19(4) 322-3
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Hematuria in Kids

• Retrospective review of 110 pts (1-18 yo) with
  blunt trauma hematuria
• All pts had imaging (CT abdo/pelvis)
• 24 pts had significant injury
• Recommend imaging if
• 50 greater RBC/HPF
• Hypotension
• Mechanism of injury

Perez, M et al. Blunt traumatic hematuria in
children Is a simplified algorithm justified? J
Urol. 2002 167(6) 2543-6.
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Renal TraumaInvestigations

• IVP vs CT?
• Only if no CT, no radiologist on call (Rosens)
• No head to head comparison in Medline

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CT vs IVP

• Major renal lacerations either have gross
  hematuria or microscopic hematuria (gt3-5 RBC/hpf)
  with shock
• IV contrast CT is best

Mee, et al. Radiographic assessment of renal
trauma a ten year prospective study of patient
selection. J Urol 1411095, 1989.
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Renal TraumaManagement

• Penetrating injury
• Presence of absence of hematuria not a factor
• Location of wound is paramount
• Pediatrics
• Any degree of hematuria is investigated

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External Genitalia Trauma

• Penile trauma
• Laceration, contusion, amputation, strangulation
• Fracture rupture of corpus cavernosum
• During vigorous intercourse, snap,
  detumescence, hematoma
• Rx - OR

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Ouch
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External Genitalia Trauma

• Testicular trauma
• Color Doppler U/S
• OR

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Conclusions

• Mechanism of injury will help the search for
  damage
• Abdo Trauma
• Occult injuries have worse morbidity/mortality
• LWE only for anterior abdo wounds
• /- oral contrast with CT
• GU Trauma
• Work from bottom to top
• Know how to do retrograde urethrogram
• If ?renal injury Gross blood or microscopic
  hypotension are indications for imaging