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Difficulty: HardTrauma and Burns

A 28-year-old construction worker is brought to the emergency department after a heavy concrete beam fell on his pelvis. His blood pressure is 118/76 mmHg and heart rate is 92/min. Primary survey reveals a patent airway and clear lungs. A pelvic binder is applied. Physical examination reveals a scrotal hematoma and blood at the urethral meatus. Arrange the following diagnostic and therapeutic steps in the correct chronological sequence to appropriately evaluate and manage this patient, assuming findings lead to the diagnosis and treatment of an intraperitoneal bladder rupture.

  1. 1Perform a FAST (Focused Assessment with Sonography for Trauma) examination
  2. 2Obtain a retrograde urethrogram
  3. 3Insert a transurethral Foley catheter
  4. 4Perform a computed tomography (CT) cystogram
  5. 5Perform an exploratory laparotomy

Answer

The correct chronological sequence is: 1) Perform a FAST examination, 2) Obtain a retrograde urethrogram, 3) Insert a transurethral Foley catheter, 4) Perform a CT cystogram, 5) Perform an exploratory laparotomy.
The algorithm for pelvic trauma with suspected urologic injury follows ATLS priorities. The FAST exam is an initial primary survey adjunct. Following this, the sequence of urologic evaluation is strictly dictated by anatomic progression and safety: the urethra must be evaluated (retrograde urethrogram) before a catheter can be placed. Once the catheter is placed, the bladder can be evaluated with contrast (CT cystogram). Finally, the diagnosis of an intraperitoneal rupture dictates operative management (exploratory laparotomy).

Step-by-Step Solution

1
Perform a FAST examination
Assesses for hemoperitoneum.
According to ATLS protocols, ruling out massive intra-abdominal hemorrhage is part of the initial primary survey adjuncts, prior to focused urologic workup.
2
Obtain a retrograde urethrogram
Evaluates the integrity of the urethra.
Blood at the urethral meatus is an absolute contraindication to blind urethral catheterization. The urethra must be visualized first to avoid converting a partial tear into a complete transection.
3
Insert a transurethral Foley catheter
Allows for bladder decompression and evaluation of urine.
After the urethra is cleared by the retrograde urethrogram, a catheter is necessary to monitor urine output and identify gross hematuria, which indicates potential bladder injury.
4
Perform a computed tomography (CT) cystogram
Identifies the presence and location of a bladder rupture.
Gross hematuria in the setting of a pelvic fracture mandates imaging of the bladder to differentiate between extraperitoneal and intraperitoneal ruptures.
5
Perform an exploratory laparotomy
Surgically repairs the bladder defect.
Unlike extraperitoneal ruptures which can often be managed with catheter drainage alone, intraperitoneal bladder ruptures leak urine into the peritoneal cavity and require urgent operative repair.

Key Concept

Sequential ATLS management of pelvic trauma complicated by suspected urologic injury.
Estimated Time:1m 30s
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Topics

Trauma and Burns

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