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Difficulty: MediumTrauma and Burns

Match each trauma patient presentation with the most appropriate immediate diagnostic test or therapeutic intervention.

  • 32-year-old with blood at the urethral meatus and a high-riding prostate following a pelvic crush injuryRetrograde urethrography
  • 27-year-old with gross hematuria and localized suprapubic pain after a direct blow to a distended bladder, with a normal urethral examinationComputed tomography (CT) cystography
  • 45-year-old with flank pain, bruising over the 11th and 12th ribs, and microscopic hematuria, with stable vital signsComputed tomography (CT) of the abdomen and pelvis with IV contrast
  • 50-year-old with an unstable pelvic ring disruption, expanding pelvic hematoma, and persistent hypotension despite a negative FAST examPelvic angiography with potential embolization

Answer

The presentations map to their respective interventions as follows: Patient 1 requires retrograde urethrography; Patient 2 requires CT cystography; Patient 3 requires CT of the abdomen and pelvis; Patient 4 requires pelvic angiography.
Each trauma presentation requires a specific diagnostic or therapeutic pathway based on ATLS guidelines. Urethral injury must be ruled out with a retrograde urethrogram before catheterization. Bladder injuries are evaluated with CT cystography. Renal injuries in stable patients require contrast CT. Unstable pelvic bleeding without intraperitoneal fluid requires angiography.

Step-by-Step Solution

1
Identify signs of urethral injury in the first patient presentation.
Blood at the meatus and a high-riding prostate are noted.
These findings contraindicate urethral catheterization until retrograde urethrography confirms the urethra is intact.
2
Evaluate the second patient presentation for bladder trauma.
Gross hematuria and suprapubic pain with a normal urethral meatus indicate likely bladder rupture.
Because the urethra is normal, a catheter can safely be placed to perform CT cystography to locate the bladder tear.
3
Assess the third patient for renal trauma.
Lower rib fractures, flank bruising, and microscopic hematuria are identified in a hemodynamically stable patient.
Hemodynamic stability allows for transport to the CT scanner for an IV contrast study to accurately stage the renal injury.
4
Analyze the hemodynamically unstable patient with a pelvic fracture.
Hypotension despite fluid resuscitation and a negative FAST exam are noted.
A negative FAST points to retroperitoneal hemorrhage rather than intraperitoneal bleeding, making pelvic angiography with embolization the next best step for hemorrhage control.

Key Concept

Genitourinary and Pelvic Trauma Evaluation
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Topics

Trauma and Burns

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