Emergency medical services bring a 26-year-old male construction worker to the trauma center after he was crushed under a collapsed retaining wall. The patient's primary survey reveals a patent airway, clear breath sounds bilaterally, and stable hemodynamics with a blood pressure of 118/76 mm Hg and a heart rate of 92/min. Secondary survey is notable for severe pelvic instability, marked perineal ecchymosis, and fresh blood visible at the urethral meatus. Digital rectal examination demonstrates a high-riding prostate. Assuming sequential workup eventually reveals a complete posterior urethral transection accompanied by an intraperitoneal bladder rupture, arrange the following management steps in the correct chronological sequence.
- 1Perform a retrograde urethrogram
- 2Place a suprapubic cystostomy tube
- 3Perform a retrograde CT cystogram
- 4Perform an exploratory laparotomy with surgical repair of the bladder dome
- 5Perform open reduction and internal fixation of the pelvic ring
Cevap
The correct sequence is: Retrograde urethrogram → Suprapubic cystostomy tube → Retrograde CT cystogram → Exploratory laparotomy → Open reduction and internal fixation of the pelvic ring.
In a hemodynamically stable patient with a severe pelvic fracture and hard signs of urethral injury, full diagnostic imaging must precede surgical intervention. The correct sequence addresses the genitourinary tract chronologically from distal to proximal. The urethra is evaluated first (retrograde urethrogram). Because it is transected, a suprapubic tube is placed to bypass the injury. Once urinary diversion is secured, the bladder can be safely evaluated (CT cystogram). The resulting diagnosis of an intraperitoneal rupture requires immediate visceral surgical repair (laparotomy). Only after the life-threatening visceral injuries are controlled should the definitive orthopedic fixation of the pelvis occur.
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Anahtar Kavram
Algorithm for suspected lower urinary tract trauma in the setting of pelvic fractures