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Pelvis, Bladder and Urethra Injury

by Kevin Pei, MD
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    00:01 Now, let’s leave the abdomen for now and go into the pelvis.

    00:05 Specific pelvic injuries are really pelvic fracture related.

    00:12 Can an eFAST detect retroperitoneal blood which is most likely associated with a pelvic fracture? The answer is no and that’s a major downfall of eFAST.

    00:23 So, just because there is no fluid in the peritoneum doesn’t mean that there is actually no bleeding in the retroperitoneum.

    00:29 That will be a miss.

    00:33 Now, take a look at these x-rays.

    00:35 This patient has a pretty bad pelvic fracture.

    00:37 In fact, you see the widening of the symphysis.

    00:40 It may be an open book pelvic fracture.

    00:43 Significant pelvic fracture like this is associated with retroperitoneal hematomas and bleeding.

    00:49 Although in general these are self-limited, in this instance on cross-sectional imaging, you also see a little bit of contrast and of course the bad pelvic fracture.

    01:01 In a patient who is unstable, and this is an important caveat, who demonstrates active extravasation instead of rushing to the operating room, what we actually do is take patient to the interventional suite after placing a pelvic binder.

    01:14 So again, remember, if you have an isolated pelvic fracture and unstable patient, you want to wrap their pelvis in a pelvic binder and then take them to the interventional suite.

    01:26 This is because unlike intra-abdominal organs that are bleeding, opening of the abdomen potentially makes the bleeding worse because the previous tamponade has been released.

    01:38 Here, you see an interventional angiography demonstrating extravasation.

    01:43 Here, our interventional radiology colleagues can do selective embolization.

    01:49 And in the lower quadrant of the image, you see the fixation.

    01:54 Oftentimes particularly when the patient is hemodynamically unstable, our orthopedic colleagues will place what’s called an external fixator just temporizing and stabilizing the pelvis so that no further bleeding occurs.

    02:07 This also reduces the volume of space that’s available in the retroperitoneum for bleeding.

    02:17 Now, what are some associated injuries with pelvic fractures? Don’t forget these, these are important.

    02:25 That’s right.

    02:26 Bladder and urethral injuries.

    02:28 Let’s go over them quickly.

    02:32 First, we’ll take a look at bladder injuries.

    02:35 In bladder injury, the most important differentiation is whether or not the bladder injury is in intraperitoneal or extraperitoneal position.

    02:44 Now, for extraperitoneal bladder injuries as demonstrated by this contrast study, there’s contrast exiting the bladder but limited itself to the extraperitoneal space.

    02:55 This is an important distinction because in this situation fully drainage alone is enough.

    03:01 As opposed to intraperitoneal bladder injury, where there is free contrast flowing or urine flowing intra-abdominally, this usually requires surgery to repair the bladder multiple layers.

    03:14 Now, remember pelvic fractures are also associated with urethral injuries.

    03:19 What are some classic exam findings of a urethral injury? Well, high-riding prostate and blood at the meatus.

    03:26 In fact, if you take ATLS or Advanced Trauma Life Support systems, these are important clinical findings that we record at every trauma activation.

    03:39 If there is suspicion of a urethral injury prior to placing a Foley catheter, you must perform a urethrogram.

    03:46 This is generally either done under fluoroscopy or under CT where contrast is place at the tip of the penis and goes retrograde into the bladder.

    03:56 Any disruption of the urethra needs to be handled by urologist.

    04:00 Although oftentimes, you’ll see the urologist simply place a stented Foley across the urethral injury obviously very carefully.

    04:09 Urethral injuries are also associated with bladder injuries.

    04:12 That’s why it’s not good enough just to look at the urethra.

    04:14 You should also look at the bladder.

    04:17 Now it’s time to review some very important clinical pearls and high-yield information.

    04:21 First, don’t take an unstable patient to the CAT scanner.

    04:24 It’s a disaster ready to happen.

    04:27 And remember, any clinical scenario presented to you where the patient becomes hemodynamically unstable requires immediate intervention, no further diagnostic studies.

    04:38 They can either go to interventional radiology for example in a patient that has a pelvic fracture or the vast majority of the time, they need an exploratory laparotomy.

    04:47 I strongly recommend that that’s the choice that you pick on your examinations.

    04:53 Thank you very much for joining me on this discussion of abdominal and pelvic injuries.


    About the Lecture

    The lecture Pelvis, Bladder and Urethra Injury by Kevin Pei, MD is from the course Surgery: Trauma. It contains the following chapters:

    • Pelvis
    • Pelvic Fracture
    • Bladder and Urethra Injury

    Included Quiz Questions

    1. Bladder and urethral injury
    2. Colon injury
    3. Kidney injury
    4. Rectal injury
    5. Abdominal injury
    1. Urethral injury
    2. Colon injury
    3. Bladder injury
    4. Rectal injury
    5. Kidney trauma
    1. Interventional radiology
    2. Fluid therapy
    3. MRI
    4. CT scan
    5. Antibiotics

    Author of lecture Pelvis, Bladder and Urethra Injury

     Kevin Pei, MD

    Kevin Pei, MD


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