Bladder Injury, Extremity Injury Flashcards Preview

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Flashcards in Bladder Injury, Extremity Injury Deck (17):
1

A 24-year-old man presents to the emergency department after being injured in a motorcycle crash. He has diastasis of his pubic symphysis, is unable to void, and has blood at his urethral meatus. What is your approach?

  • Blunt trauma, FAST positive w/ instability - OR for ex-lap
  • Unstable w/ neg FAST - wrap pelvis; can get DPL or pelvic XR 
    • DPL positive - OR for pelvic stabilization, preperitoneal packing
    • Can wrap knees in internal rotation and do REBOA
  • Stabilizes w/ resuscitation - CT scan, IR for embolization
  • Blood at urethral meatus - suspect urethral injury: RUG, Foley, retro CT cysto

2

A 42-year-old woman is injured in an occurrence of domestic violence. She has a gunshot wound that enters the left suprapubic area and exits from the right buttock, and she has gross hematuria. How will you manage this patient?

  • ABC; Secondary should include DRE and vaginal exam; FAST
  • Gross hematuria - suspect bladder rupture (95%) - retrograde CT cysto
    • If no signs of urethral injury, can attempt Foley x1 vs RUG before cysto
  • XR pelvis - retained FBCT w/ IV con & delays - ureter injury
  • Injury to the external genitalia: OR repair (esp corpora cavernosa in male)
  • Intraperitoneal fluid: OR repair - bladder, colon/rectum repaired primarily
    • extraperitoneal rectum should get proximal diversion (EAST)
      • no presacral drainage or distal rectal washoud (EAST)
  • Extraperitoneal bladder injury: Foley for 2 weeks

3

A 54-year-old man sustains a pelvic crush injury following blunt abdominal trauma. Microscopic hematuria (> 25 red blood cells/high-power field) is noted on urinalysis. What do you recommend?

  • ABC - resuscitate
  • cannot resuscitate - OR
  • stable - retrograde CT cysto 
    • bleeding - IR embo
    • intraperitoneal fluid - OR
    • extraperitoneal extrav - Foley

4

You are performing an exploratory laparotomy for blunt abdominal trauma. There is a hematoma surrounding the bladder and urinary extravasation. How will you manage this patient?

  • systemic eval - ureters, trigone, bladder neck 
  • repair the bladder primarily if dome injury - 2 layers, 2-0 absorbable
  • do NOT dissect in the pelvis if bladder unable to be repaired from dome
    • can open the dome and repair the extraperitoneal bladder injury intravesicularly in 1 layer, then close the dome in 2 layers

5

A 58-year-old man presents to the emergency department after being kicked in the lower abdomen by a horse. He is complaining of abdominal pain, and he has hematuria. Cystography reveals "flame-shaped" contrast extravasation. How will you manage this patient?

  • Dx: extraperitoneal bladder rupture
  • Tx: nonoperative,  catheter drainage 
    • exceptions: invovling the neck, associated rectal/vaginal injury, laparotomy for other conditions 

6

A male patient with GCS 14 presents after blunt trauma with pelvic tenderness and a scrotal hematoma. What is your initial approach to evaluating this patient in the resuscitation room?

During your initial assessment, the patient in Question 1 becomes hemodynamically unstable. How will you evaluate and treat shock in the trauma bay?

  • ABC and secondary
  • FAST - if exam positive and HD unstable - ex-lap - preperitoneal packing
  • if instability on pelvis on exam - suspect pelvic fractures - binder
  • If HD unstable - resuscitate and get pelvic XR
    • responsive - CT and angio embolization
    • unresponsive - ex-lap 
  • suspect urethral injury - RUG

7

Assuming the patient has a confirmed open-book pelvic fracture on AP radiograph and remains hemodynamically unstable after initial resuscitation, how will workup in the trauma bay guide your decision on the most appropriate treatment?

  • already done ABC, pelvic XR
  • place in binder
  • The rest of the management depends on where the bleeding is...
  • FAST: Is it in the abdomen or pelvis?
    • positive - OR ex-lap for peritoneal bleeding
    • negative - IR angio embolization for pelvic bleeding

8

In an adult suspected of having bladder trauma, what volume of contrast should be instilled into the bladder for imaging and how many films are required?

  • exclude urethral injury in stable patient and place Foley
  • patient should be supine and have baseline KUB
  • 400 mL of 10% water soluble contrast, wait for contrast to pass
    • if contraction, wait for it to pass, fill to point of contraction, force 50 ml
  • clamp the catheter, and obtain second KUB

9

Extraperitoneal bladder ruptures may be managed non-operatively under what circumstances?

Stable patients w/o vaginal/rectal injuries or other indications for laparotomy

10

A 37-year-old morbidly obese female falls while descending stairs and has immediate pain and gross deformity of the left knee. What is your approach to the diagnosis and management of this patient?

  • Acute trauma knee pain: note the amount of swelling
    • Large: ACL/PCL, meniscus, intra-articular fracture, osteochondral defect, patellar dislocation/tendon tear, quad injury, knee dislocation
    • Small: partial tears, strains, fibula fx
  • H&P: palpation, RoM, neurovascular 
  • Imaging: 2 view XRs for >55 yrs, loss of RoM, inability to bear weight, point tender
  • May require MRI if instability w/o fracture 
  • Knee dislocation: often w/ vascular injury; direct blow, obese people who fall
    • reduce, ABI/NV/Duplex, consult ortho/vascular

11

A 33-year-old male is involved in a high-speed rollover motor vehicle accident. Upon presentation, he complains of right hip pain. His right leg is mildly shortened on visual inspection and is held in a position of adduction and internal rotation. What is your approach to the diagnosis and management of this patient?

  • ABCs, secondary exam
  • suspect hip dislocation, likely posterior, may have associated fx
  • NV exam - associated sciatic injury
  • pelvic imaging - AP/lateral XRs 
  • closed reduction - sedate, supine, traction in line w/ deformity; prevent osteonec
  • post-reduction CT - look for femoral head fx, loose bodies, acetab fx - ORIF
  • protected weight bearing x4-6 wks

12

A 28-year-old female with epilepsy presents to the Emergency Department following a generalized seizure. Witnesses were able to lower her to the ground and deny any trauma to her body or head. The patient remains confused and uncooperative with your exam; however, it is difficult to move her right upper extremity, which is maintained adducted and internally rotated against her abdomen. It is unclear whether she is guarding the extremity, but upon examination of her other extremities, you find unrestricted range of motion. What is your approach to the diagnosis and management of this patient?

  • Suspect posterior dislocation: 2-4%; seizure, electroction, ant blow to shoulder
  • Associated with tuberosity and surgical neck fractures, rotator cuff injuries
    • assess neurovascular status 
    • 2 view XRs
    • CT if indeterminate 
    • reduce - axial traction, internal rotation and adduction, posterior to anterior pressure, immobilized in neutral position 

13

A 22 year-old male involved in a motorcycle collision presents to your hospital with a decreased blood pressure and increased heart rate. He is noted to have bilateral thigh deformities with open wounds draining fracture hematoma. What is your approach to evaluating and treating this patient?

  • ABCs - likely multiple injuries; resuscitate and address these
  • assess NV injury - if present, control pain and reduce fractures, reassess NV
  • suspect BL femur fxs - AP/lateral XRs to the thigh, include hip and knee 
  • open fractures: tetanus, abx, early washout
  • severe concomitant injuries: damage control - external fix, delayed definitive repair

14

A 38 year-old morbidly obese female sustains a knee dislocation while stepping off a curb. In your ED, she is found to have a pulse, but only by Doppler evaluation. What is your approach to the diagnosis and treatment of this patient?

  • Approach with possibility of threatened limb
  • Reduce fracture under sedation
  • check pulses, ABI, neuro, Duplex 
    • strong pulse, ABI 0.9, Duplex nl - obs, ortho consult
    • asymmetric pulse, ABI <0.9, Duplex abn - arteriogram, vascular and ortho consult
    • weak pulse, ischemia evident (pale, dusky, paresthesia, paralysis) - OR vascular emergency

15

A 54 year-old male presents to your hospital after sustaining a GSW to his tibia while on a hunting trip with his high powered rifle. His transport from the field took 4 hours to arrive in the ED, and EMS reports transient hypotension. On presentation, his foot is cool and pulseless. What is your approach to evaluating and treating this patient?

  • resuscitate, control active hemorrhage, examine - neurovasc, compartments, skin, bones - mangled extremity score 
    • hard signs: active hemorrhage, expanding/pulsatile hematoma, bruit/thrill, absent pulses, pain/pallor/paralysis/poikilothermia 
  • ppx abx, tetanus 
  • AP/lateral XRs to include above and below joint
  • CTA eval vasculature - decide amputation vs limb salvage (life over limb)
  • repair vasculature if needed and consider ppx fasciotomies (6 hrs ischemia time)
  • repair orthopedic injuries
  • watch for rhabdomyolysis 

16

You are performing a flexor tendon repair in the hand. You find an FDS injury at the level of the proximal phalanx. What will you do?

  • FDS - flex PIP, assist flex MCP
  • >60% tendon width - operative repair
  • preserve A2 and A4 pulley
  • post-op splinting w/ controlled mobilization 

17

A young male presents to the Emergency Department intoxicated with absent extension of the long finger and a laceration over the dorsal metacarpophalangeal joint of this digit. What do you suspect is the mechanism of injury? What is your major concern? What is optimal management?

  • "fight bite": knuckle vs tooth, 3/4 MCP of dom hand, young male, delayed psx
  • concern for tendon injury: depends on hand posture at time of injury
  • concern for infx of MCP w/ oral + skin flora: GAS, Staph, Eikenella corrodens
  • management: acute washout of the joint, IV abx
    • delayed intervention is not an appropriate option in a hand bite
    • hands bites have high infx rates: use amp/sul, zosyn, cef3/flagyl
    • consider tetanus (no need if 3 doses given < 5 yrs ago)
    • ​repair tendon if >50% damage 
    • ​do not primarily close - delayed closure