A 24-year-old motorcyclist is brought into the Emergency department with a ‘severe’ pelvic fracture following a road traffic accident. Associated injuries mean that monitoring of urine output is required by the trauma team. What factor would immediately raise the suspicion of an associated urethral injury?
Answer A
You are asked by the Gynaecology SPR to see a patient who had an abdominal hysterectomy 48 hours ago. The patient is tachycardic, pyrexial (39.2) and complaining of left flank pain. There is abdominal and left flank tenderness, and drainage of 500 mL of blood stained fluid in the last 12 hours from the pelvic drain. FBC – Hb 10.2, WCC 15.0. Electrolytes are normal. The next step in management is to:
Answer C
This patient has a urological injury until proven otherwise. It is essential to determine what injuries exist – right or left ureter, bladder or a combination. Contrast imaging is essential followed by nephrostomy in this sick patient. Once the patient is better, reconstruction can be considered.
An 18-year-old male is brought in to the Emergency department after being stabbed in the right loin. There is no further history available. The patient’s blood pressure is poorly maintained with intravenous fluids but stabilises with a 2 unit blood transfusion. Contrast CT shows a Grade 4 Right renal injury. There is no suspected intra-abdominal injury. What is the next step in management?
The so-called ‘ultraconservative’ approach to renal salvage should be followed in centres with the correct expertise. With the centralisation of trauma, these cases should not be managed in centres without 24 hours on call interventional radiology. Bleeding is the first priority and this should be controlled by selective angioembolisation. In the setting of urinary extravasation and penetrating trauma, embolisation should be followed by insertion of a ureteric stent. Unstable patients cannot be managed conservatively but operative intervention is likely to lead to nephrectomy.
A 39-year-old male is brought to the Emergency Department complaining of severe lower abdominal pain and an inability to void. He had been involved in an altercation following a ‘heavy’ drinking session. He vaguely remembers being punched to the head and lower abdomen. He did not lose consciousness and has been assessed as having only a minor head injury. Examination reveals a stable patient with lower abdominal tenderness, but no obvious palpable bladder. Blood and urine tests are normal. What is the investigation would you consider next?
Answer D
This patient’s most likely diagnosis is an intraperitoneal bladder rupture from a direct blow to a full bladder. A stress cystogram is the investigation of choice in suspected bladder injuries. However intraperitoneal ruptures will lead to early contrast extravasation so neither the full volume (nor full strength contrast) should be used in these cases in the first instance.
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