A 31-year-old motorcyclist is brought to the emergency department after a collision in which he had a direct blow to his lower abdomen and pelvis. Blood pressure is 110/80 mm Hg, pulse is 102/min, and respirations are 18/min. The airway is intact, and breath and heart sounds are normal. There is suprapubic tenderness to palpation with bruising. Chest x-ray reveals no fractures. Pelvic x-ray shows widening of the pubic symphysis. Focused Assessment with Sonography for Trauma reveals intraperitoneal free fluid. Urine dipstick test is positive for blood. Which of the following is the best next step in management of this patient?

Question

A 31-year-old motorcyclist is brought to the emergency department after a collision in which he had a direct blow to his lower abdomen and pelvis.  Blood pressure is 110/80 mm Hg, pulse is 102/min, and respirations are 18/min.  The airway is intact, and breath and heart sounds are normal.  There is suprapubic tenderness to palpation with bruising.  Chest x-ray reveals no fractures.  Pelvic x-ray shows widening of the pubic symphysis.  Focused Assessment with Sonography for Trauma reveals intraperitoneal free fluid.  Urine dipstick test is positive for blood.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d956_212a_bc81_815a373f9004_MD0003_00 This patient with blunt abdominal trauma (BAT) has suprapubic tenderness, hematuria, and intraperitoneal free fluid (eg, urine) on Focused Assessment with Sonography for Trauma (FAST). This presentation is most concerning for intraperitoneal bladder rupture and should be evaluated with cystography. Blunt lower abdominal trauma can abruptly increase intravesical pressure and rupture the bladder at its weakest part (ie, dome). Peritonitis often does not develop acutely because urine is typically sterile. Instead, the most common clinical findings of bladder rupture are: hematuria (~90%). suprapubic tenderness. difficulty voiding. associated pelvic fracture (eg, widening of the pubic symphysis). Retrograde cystography, in which the bladder is passively filled (eg, via Foley catheter) with water-soluble contrast and then imaged (eg, CT scan), can confirm the diagnosis. Surgical repair is typically required for intraperitoneal rupture because continued efflux of urine through the defect prevents spontaneous healing. (Choice A) In the triage of BAT patients, diagnostic peritoneal lavage may be used to evaluate hemodynamically unstable (eg, systolic blood pressure <90 mm Hg) patients for intraabdominal hemorrhage (which would necessitate immediate laparotomy). This patient is hemodynamically stable and can tolerate further testing (eg, CT scan with cystography) to determine the source of his intraperitoneal free fluid (eg, urine). triage of BAT patients (Choice B) Prior to widespread CT scan availability, intravenous pyelography (IVP) was used to detect kidney stones and renal/urothelial neoplasms. In IVP, intravenous contrast is followed in an anterograde manner through the kidneys, ureters, and bladder via serial x-rays. Although IVP can possibly detect contrast extravasation from a ruptured bladder, the slow, anterograde filling of the bladder with contrast is significantly less sensitive than cystography's rapid, retrograde instillation of contrast. (Choice C) Renal ultrasonography may be used to evaluate for renal injury, which can occur from blunt abdominal trauma (due to compression against the paravertebral muscles) and result in hematuria. However, renal injury more typically causes retroperitoneal (vs intraperitoneal) free fluid and flank (vs suprapubic) pain. (Choice E) Transrectal ultrasonography is commonly used to evaluate the prostate following abnormal digital rectal examination. It is typically performed electively in the setting of suspected prostate cancer and does not evaluate the bladder, which is likely injured in this patient. Educational objective: Blunt lower abdominal trauma can rupture the bladder at its weakest part (ie, dome), spilling urine into the intraperitoneal cavity. Common clinical findings include hematuria, suprapubic tenderness, difficulty voiding, and associated pelvic fracture. References: A contemporary review of adult bladder trauma. (http://www.ncbi.nlm.nih.gov/pubmed/30979861) Blunt bladder injury. (http://www.ncbi.nlm.nih.gov/pubmed/23522505)

A 31-Year-Old Motorcyclist Is Brought to the Emergency Department After