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272
L. Weil
– Should be considered for patients that are severely
hemodynamically unstable, have massive blood loss,
coagulopathic, acidotic, and hypothermic.
– This procedure involved controlling hemorrhage rst,
then controlling hollow viscus injury and associated
contamination with sutures or a resection but without
an anastomosis. Placement of an abdominal wound
vacuum-assisted closure and planned return to the OR
within 24–48h.
Clean Kills
• Not following the primary survey with a trauma patient.
• Trying to do a primary repair of an injury ≥50% of the
bowel lumen circumference.
• Not looking for other injuries.
• Doing an anastomosis on a patient that is too unstable.
Bonus Points
• Left-sided injuries no longer require diversion. If the
injury is small and the patient is stable, we can do a primary repair on a left-sided colon injury.
• Even if a primary repair is an appropriate surgical plan, be
prepared and know how to manage a patient that leaks.
• There are equal complication rates between stapled and
hand-sewn anastomosis.
Words ofWisdom
• In a trauma setting, always start with the primary survey
rst. Do not skip the secondary survey.
• Always deal with life-threatening injuries rst.
• Do not forget to look for other injuries. Run the bowel to
avoid a missed bowel injury.
• If one is worried about the patient’s ability to heal an
anastomosis, the safest answer is diversion.
• Do not forget that a damage control procedure is appropriate on the right patient.
• The specic repair technique depends on the type and
extent of the injury. Be comfortable describing a primary
repair, resection and anastomosis, diverting colostomy
and a damage control procedure.
Bibliography
Injury scoring scale. The American Association for the Surgery of
Trauma. 2023 Aug 17. https://www.aast.org/resources- detail/
injury- scoring- scale
Further Reading
Score. Available from: https://www.surgicalcore.org/modulecontent.
aspx?id=1000449
Rectal Trauma
MichaelD.Cline
85
Way Question May BeAsked?
A young male is a status post gunshot wound to the right
lower quadrant. The primary survey demonstrates tachycardia and hypotension. Adjuncts are notable for a retained
missile projecting over the left pelvis. The secondary survey
is notable for peritonitis and gross blood on rectal
examination.
A middle-aged female is a status post-high-speed motor
vehicle accident. The primary survey is notable for tachycardia. Adjuncts are notable for symphysis pubis diastasis. The
secondary survey demonstrates gross blood on rectal
examination.
How toAnswer?
• History and physical examination (ATLS)
– Prehospital report of circumstances and interventions.
– Primary survey (airway and cervical spine immobili-
zation, breathing and ventilation, circulation with
hemorrhage control, disability, exposure, and environmental control).
– Adjuncts to the primary survey (CXR, KUB, pelvic
x-ray, eFAST).
– Secondary survey
Particular attention to peritonitis and gross blood on
digital rectal examination (DRE).
– AMPLE history (allergies, medications, past medical
and surgical history, last meal, events).
• Diagnostic evaluation
– Hemodynamic stability: CT abdomen/pelvis with IV
contrast +/− rectal contrast.
M. D. Cline (*)
Lewis Katz School of Medicine at Temple University,
Philadelphia, PA, USA
e-mail: Michael.Cline@jefferson.edu
– If DRE or CT is equivocal for extraperitoneal rectal
injury, rigid proctoscopy or exible sigmoidoscopy
should be performed.
– Hemodynamic instability: eFAST or diagnostic perito-
neal lavage or aspiration (DPA/DPL) if eFAST is
unavailable or equivocal.
– Peritonitis: laparotomy.
– If there is concern for a concomitant extraperitoneal
rectal injury, rigid proctoscopy or exible sigmoidos-
copy should be performed.
• Management
– General principles
Identify the location of injury: intraperitoneal or
extraperitoneal.
Determine the extent of injury
• Non-destructive: <50% of circumference without devascularization.
• Destructive: ≥50% of circumference and/or
devascularization.
– Determine if high-risk for abdominal complications
when considering whether to perform an anastomosis.
Hemodynamic instability and/or severe metabolic
derangements.
Several fecal contamination.
Transfusion of ≥4 packed red blood cells (PRBC).
– Intraperitoneal rectal injury—management is similar
to colon injury (see Chap. 84).
Non-destructive injury—debridement and
colorrhaphy.
Destructive injury.
• No high-risk features—segmental resection and
anastomosis; may consider diverting loop
ileostomy.
• High-risk features—Hartmann’s procedure.
– Severe hemodynamic instability and/or severe meta-
bolic derangements necessitating a damage control
operation: segmental resection and temporary abdominal closure.
– Extraperitoneal rectal injury: fecal diversion (loop
colostomy).
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_85
273
274
M. D. Cline
Common Curveballs
• Concomitant intra-abdominal and/or extra-abdominal
injuries: manage as appropriate with consideration of performing a damage control operation.
• Severe hemodynamic instability and/or severe metabolic
derangements: perform a damage control operation.
• Postoperative anastomotic dehiscence: management
depends on postoperative day, hemodynamic status, and
the presence or absence of sepsis and/or peritonitis.
– Variables favoring operative management: hemody-
namic instability, sepsis, peritonitis, <7 days
postoperative.
– Operative management: resection and end
colostomy.
– Non-operative management: antimicrobial therapy
+/− percutaneous drainage (manage as colocutaneous
stula).
Clean Kills
• Failure to triage the patient utilizing the principles of
ATLS.
• Failure to diagnose and manage concomitant injuries.
• Failure to distinguish between intraperitoneal and extraperitoneal as well as destructive and non-destructive injuries when determining management approach.
• Failure to account for the patient’s hemodynamic and
metabolic status when considering anastomosis or fecal
diversion.
Words ofWisdom
As in all trauma patients, adherence to the principles of
ATLS is paramount in appropriately triaging the patient and
excluding concomitant, life-threatening injuries. Diagnosis
relies upon DRE, CT, and/or rigid proctoscopy or exible
sigmoidoscopy. Management is dictated by the location
(intra- or extra-peritoneal) and extent (destructive or nondestructive) of the injury as well as the hemodynamic and
metabolic status of the patient (primary repair or fecal
diversion).
Bibliography
Asensio JA, Trunkey DD.Current therapy of trauma and surgical criti-
cal care. 2nd ed. Philadelphia: Elsevier; 2015.
Bosarge PL, Como JJ, Fox N, et al. Management of penetrating
extraperitoneal rectal injuries: an Eastern Association for the
Surgery of Trauma practice management guideline. J Trauma
Acute Care Surg. 2016;80(3):546–51. https://doi.org/10.1097/
TA.0000000000000953.
Cullinane DC, Jawa RS, Como JJ, etal. Management of penetrating
intraperitoneal colon injuries: a meta-analysis and practice management guideline from the Eastern Association for the Surgery of
Trauma. J Trauma Acute Care Surg. 2019;86(3):505–15. https://doi.
org/10.1097/TA.0000000000002146.
Extremity Compartment Syndrome
MichaelD.Cline
86
Way Question May BeAsked?
Example 86.1
Following bifemoral cannulation for VA ECMO, your patient
develops lower extremity ischemia. Several hours following
the placement of a distal perfusion cannula, the ipsilateral
lower extremity has become progressively edematous and
rm.
Example 86.2
During the resuscitation of a patient with a 65% TBSA thermal burn, the nurse calls you given concern for increasing
rmness of the bilateral upper extremities.
Example 86.3
During your triage of a trauma patient who was “found
down,” your secondary survey is notable for tenderness and
rmness of the bilateral buttocks and thighs.
Example 86.4
After management of a transfemoral penetrating injury with
femoral artery interposition grafting and femoral vein ligation, is there anything else you would like to assess prior to
leaving the operating room?
Physical Examination
• Pain with passive range of motion (early)
• Tense, noncompressible compartment
• Impaired sensation
– First web space, deep peroneal nerve, anterior
compartment
– Dorsum of foot, supercial peroneal nerve, lateral
compartment
– Plantar surface, tibial nerve, deep posterior
compartment
• Decreased motor strength
• Paralysis or pulselessness (late)
Diagnostic Evaluation
• Clinical diagnosis (compartment pressures may be measured to conrm the diagnosis or if uncertainty exists)
• Compartment pressure measurement
– Commercial device (Stryker)
– Needle–manometer system (16-gauge needle con-
nected to an arterial line setup via a three-way stopcock, zero system at the level of the limb, inject 1cc of
saline, measure compartment pressure)
• Creatine kinase (CK) is unnecessary for the diagnosis of
compartment syndrome but valuable in the evaluation and
management of rhabdomyolysis
How toAnswer?
Surgical Management
History
• Presentation (trauma, burn, crush, prolonged immobility,
revascularization)
• Pain out of proportion to injury
• Paresthesia
M. D. Cline (*)
Lewis Katz School of Medicine at Temple University,
Philadelphia, PA, USA
e-mail: Michael.Cline@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_86
• Leg fasciotomy
– If initial evaluation is inconsistent with compartment
syndrome, interval assessments are necessary to
exclude its subsequent development
– Indications for fasciotomy
Clinical diagnosis of compartment syndrome
Delta pressure (diastolic blood pressure—measured
compartment syndrome)<30mmHg
– Calf fasciotomy (two-incision technique)
Lateral incision (anterior and lateral compartments)
is positioned between the tibia and bula from
275
276
M. D. Cline
2–3 cm distal to the tibial tuberosity to 2–3 cm
proximal to the lateral malleolus
Incise the fascia anterior and posterior to the intermuscular septum
Protect the supercial peroneal nerve as it assumes
a subcutaneous position in the distal third of the leg
– Medial incision (supercial and deep posterior com-
partments) is positioned 1–2cm posterior to the tibia
from 2–3cm distal to the tibial tuberosity to 2–3cm
proximal to the medial malleolus
– Incise the fascia of the supercial deep compartment
and then mobilize the soleus from the posterior aspect
of the tibia to decompress the deep posterior
compartment
– Protect the great saphenous vein
• Gluteal fasciotomy
– Question mark incision (curvilinear incision connect-
ing the posterior superior iliac spine, greater trochanter, and the midline posterior thigh) or longitudinal
incision (linear incision connecting the posterior super
iliac spine, greater trochanter, and lateral thigh)
– Incise the fascia of the gluteus maximus, bluntly
spread the gluteus maximus, incise the fascia of the
gluteus medius and minimus, incise the tensor fascia
lata distally
• Thigh fasciotomy
– Lateral incision (anterior and posterior compartments)
extending from the greater trochanter to 3–5cm proximal to the lateral femoral condyle
Incise the fascia anterior and posterior to the intermuscular septum; may require posterior ap
mobilization
– Medial incision (medial compartment), which is rarely
needed, extends along the course of the great saphenous vein to 3–5cm proximal to the medial femoral
condyle
• Forearm fasciotomy
– Anterior lazy S (volar compartment) and posterior lon-
gitudinal (dorsal compartment) incisions
• Hypotensive patient
– Utilize delta pressure (<30 mmHg) rather than abso-
lute compartment pressure (>30 mmHg) in conjunction with physical examination
• Compartment syndrome conned to a specic
compartment
– Examine and/or measure pressures in all compart-
ments of the affected extremity, as certain compartments may remain unaffected
• Persistent signs/symptoms following fasciotomy
– Examine each of the compartments of the affected
extremity to exclude a missed compartment or incomplete fasciotomy
Clean Kills
• Failure to or delay in diagnosing compartment syndrome
• Inability to describe the operative conduct
• Missed compartment or incomplete fasciotomy
Words ofWisdom
Acute compartment syndrome of the extremity, whose etiologies are numerous, results in myocutaneous and nervous
tissue ischemia producing the characteristic signs and symptoms of pain, pallor, paresthesia, and impaired sensation and
strength. Diagnosis, while primarily clinical, may be supported by measurement of compartment pressures. A key
factor is to describe continued interval assessments in
patients at risk, as compartment syndrome may evolve over
time. Management consists of emergent fasciotomy to
decompress the compartment, restore adequate perfusion,
and avoid the morbidity associated with impaired limb function or amputation, as well as rhabdomyolysis and renal
failure.
Bibliography
Common Curveballs
• Encephalopathic patient or inability to obtain a complete
physical examination (sedated patient)
– Maintain a high index of suspicion and/or obtain com-
partment pressures
• Delayed development of compartment syndrome
– Initial evaluation following revascularization demon-
strated a soft compartment, but hours later, the compartment is tense; perform interval evaluation(s)
Köstler W, Strohm PC, Südkamp NP. Acute compartment syndrome
of the limb. Injury. 2004;35(12):1221–7. https://doi.org/10.1016/j.
injury.2004.04.009. Erratum in: Injury. 2005 Aug;36(8):991.
Corrected and republished in: Injury. 2005 Aug;36(8):992-8. https://
doi.org/10.1016/j.injury.2005.01.007. PMID: 15561110.
Mubarak S, Owen C. Double-incision fasciotomy of the leg for
decompression in compartment syndromes. J Bone Joint Surg Am.
1977;59(2):184–7.
Duodenal Trauma
LiaMichos andAnirudhKohli
87
Duodenal Injury Grading
• Grade 1: hematoma involving only one portion of the
duodenum or partial thickness laceration that is not
perforated.
• Grade 2: hematoma that involves more than one portion
of the duodenum or laceration, which is <50% of the circumference of the duodenal wall.
• Grade 3: 50–75% circumference laceration of D2 or
50–100% circumference laceration of D1, D3, or D4.
• Grade 4: >75% circumference laceration of D2 involving
the ampulla and/or distal common bile duct.
• Grade 5: massive disruption/devascularization of the duodenopancreatic complex.
Way Question May BeAsked?
A 37-year-old male presents to the trauma bay with a gunshot wound (GSW) to the right ank. Airway is intact and
bilateral breath sounds are heard. Vitals are as follows: HR
130, BP 94/62, RR 22, O2 saturation 97% on room air. GCS
15. A chest X-ray is within normal limits. An abdominal
X-ray shows a bullet seen in the left side of abdomen, with
free intraperitoneal air. A large bore central venous catheter
is placed, and a massive transfusion protocol is activated.
On secondary survey, you do not nd any other injuries or
GSWs. What are your next steps?
L. Michos
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
e-mail: lia.michos@jefferson.edu
A. Kohli (
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
Division of Acute Care Surgery, Department of Surgery, Thomas
Jefferson University Hospital, Philadelphia, PA, USA
e-mail: anirudh.kohli@jefferson.edu
*)
How toAnswer?
• You know the bullet is in the abdomen, so you should
proceed to the operating room.
• If the patient is protecting their airway, have anesthesia
intubate the patient in the OR in order to quickly perform
a crash laparotomy if needed.
• Prep the patient from chin to knees.
• Begin with an exploratory laparotomy. Communicate
with anesthesia prior to making the incision that they have
blood available and are ready.
• If blood is encountered, pack all four quadrants.
Alternate Scenario
A 37-year-old male presents to the trauma bay after a motor
vehicle crash. He was the restrained driver in a vehicle driving at about 60 miles per hour and collided with the car in
front of him as they stopped short. His airway is intact, and
bilateral breath sounds are heard. Vitals are as follows: HR
110, BP 100/62, RR 22, O2 saturation 97% on 6L NC.GCS
15. Chest X-ray is within normal limits. FAST is negative.
Two large bore IVs are placed. Secondary survey shows a
2cm laceration to the right forehead, seatbelt sign across the
upper abdomen, and a deformity of the right wrist. The
patient has a C-collar in place, which was placed by EMS at
the scene. Repeat vital signs show an HR 103, BP 122/88,
RR 20, and O2 saturation of 98% on room air. The patient is
stable, so you take him to the CT scanner for a CT head,
c-spine, chest, abdomen, and pelvis, which shows a duodenal
hematoma involving D1, a Grade 2 right kidney laceration,
and Grade 1 splenic laceration. What are your next steps?
• If he remains stable, you can treat him conservatively
with bowel rest, with or without an NGT.
• Place the patient in the ICU and monitor his hemoglobin
with serial hemoglobin/hematocrit levels.
• Do not forget to order X-rays of his right wrist once stable
and in the ICU to evaluate for injury.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_87
277
278
L. Michos and A. Kohli
• Consider obtaining a CT with gastrogran through his nasogastric tube or by mouth once stabilized to determine if
there is any ow of contrast past the duodenal hematoma.
What are the imaging ndings suggestive of duodenal
injury?
• duodenal wall thickening
• free uid around the duodenum
• uid in the right pararenal space
• hypo-enhancement of the duodenal wall
• extravasation of oral contrast into the lesser sac
• “coiled spring sign”: can be seen when there is an
obstructing duodenal hematoma
How do you manage each type of duodenal injury grade?
• Grade 1 and Grade 2 duodenal hematomas are usually
managed nonoperatively. Surgical intervention is reserved
for those who fail nonoperative management, usually
after 3 weeks. Surgical intervention consists of evacuation of the duodenal hematoma with a simple two-layered
repair.
• Grade 1 lacerations are repaired by a Lembert suture.
• Grade 2 full-thickness lacerations are debrided and
repaired by primary closure in two layers with an absorbable inner layer and a nonabsorbable outer layer.
Remember to close longitudinal injuries transversely so
as to not narrow the lumen.
• Grade 3 lacerations can also usually be debrided and primarily closed in two layers. If a primary repair cannot be
performed, then the patient should undergo resection with
anastomosis by duodenoduodenostomy.
– A pyloric exclusion with gastrojejunostomy should
also be considered to protect the duodenoduodenostomy for a tenuous repair.
– If the defect is too large, then a duodenojejunostomy
with Roux-en-Y reconstruction should be done.
• Grade 4/5 injuries in patients who are unstable should
undergo suture repair of the duodenal laceration and wide
drainage with a staged Whipple procedure.
What is the role of conservative management in duodenal
injuries?
• Most duodenal hematomas resolve without intervention.
Conservative management of duodenal hematomas consists of nasogastric decompression or bowel rest with no
nasogastric tube and nutritional support, often with total
parenteral nutrition.
How do you expose the duodenum?
• To expose D1 and D2, perform an extended Kocher
maneuver. For exposing D2 further, D3 and D4 a Cattell–
Braasch maneuver (right medial visceral rotation) is done.
You can also mobilize the ligament of Treitz to expose D4
further.
What are the major complications and their correspond-
ing management after duodenal repair?
• Some of the complications post duodenal repair include
formation of an intra-abdominal abscess that can be
either drained if accessible or monitored on intravenous antibiotics; gastrointestinal bleeding that can be
managed with blood transfusion, angiography with
possible embolization, stress ulcer treatment and prophylaxis, possible endoscopic intervention; breakdown
of anastomosis—may need drainage with antibiotics
versus operative intervention if the patient is in septic
shock and it is an early leak likely from technical
factors.
Clean Kills
• Taking the unstable patient with a GSW to the CT scanner
instead of proceeding to the operating room
immediately.
• Not systematically completing your trauma assessment
• Missing other injuries, including outside the abdominal
cavity or within the abdominal cavity
• Failure to place a jejunal feeding tube or thinking about
enteral access in the OR?
• Taking the stable patient to the OR for a duodenal
hematoma?
Bonus Points
• When a duodenal hematoma is encountered during a
trauma laparotomy, assess for luminal compromise, and if
that is thought to be more than 50%, then drain the hematoma and perform a simple repair
• In a complex multi-trauma situation with a longanticipated recovery time consider placement of feeding
access and can potentially consider a gastro-jejunostomy
tube for drainage and feeding with the same tube.
87 Duodenal Trauma
279
Words ofWisdom
Duodenal trauma has a low overall incidence but a high rate
of mortality and morbidity associated with it due to delays in
diagnosis and missed injuries. Hence, a high index of suspicion based on the mechanism of injury and signs/symptoms
is paramount. If recognized early and effectively managed
the complication rate is much lower. With blunt traumatic
injury in a stable patient, one must consider performing
cross-sectional imaging with intravenous contrast and if possible with oral contrast as well to rule out a major duodenal
injury. Healing from this injury depends on adequate blood
supply to the repair, minimizing contamination, and optimizing nutrition (preferably enteral nutrition.)
Further Reading
Management of duodenal trauma in adults. https://
www.uptodate.com/contents/management- ofduodenal- trauma- in- adults?search=duodenal%20
trauma&source=search_result&selectedTitle=1~150&usa
ge_type=default&display_rank=1#H2054906.
Malhotra A, Bif WL, Moore EE, Schreiber M, Albrecht RA, Cohen
M, Croce M, Karmy-Jones R, Namias N, Rowell S, Shatz DV,
Brasel KJ.Western Trauma Association critical decisions in trauma:
diagnosis and management of duodenal injuries
SCORE. https://www.surgicalcore.org/modulecontent.
aspx?id=1000527.
Genitourinary Trauma
LiaMichos andAnirudhKohli
88
Renal Injury Grading (Lewis 2023; Peitzman
etal. 2020)
• Grade 1: contusion causing microscopic or gross hematuria with normal urologic studies or a hematoma that is
subcapsular, non-expanding, and does not have a parenchymal laceration
• Grade 2: nonexpanding perirenal hematoma, which is
conned to the Gerota’s fascia or a laceration that is
<1cm and without urinary extravasation
• Grade 3: >1cm laceration without urinary extravasation
or active bleeding in the Gerota’s fascia
• Grade 4: laceration extending through the renal cortex,
collecting system, and medulla or a segmental renal artery
or renal vein injury
• Grade 5: main renal artery or vein laceration or avulsion
of renal hilum or completely shattered kidney
Ureter Injury Grading (Peitzman etal. 2020)
• Grade 1: contusion or hematoma without
devascularization
• Grade 2: <50% ureteral transection
• Grade 3: >50% ureteral transection
• Grade 4: Complete ureteral transection with <2 cm of
devascularization
• Grade 5: avulsion of the ureter with >2 cm of
devascularization
Bladder Injury Grading (Peitzman etal.
2020)
• Grade 1: contusion or intramural hematoma or a partial
thickness laceration
• Grade 2: Extraperitoneal bladder laceration that is <2cm
• Grade 3: Extraperitoneal laceration >2cm or intraperitoneal laceration <2cm
• Grade 4: intraperitoneal bladder laceration that is >2cm
• Grade 5: extraperitoneal or intraperitoneal bladder wall
laceration extending into the bladder neck or trigone (ureteral orice)
Urethral Injury Grading
• Type 1: Posterior urethra is stretched but intact.
• Type 2: Pure posterior urethral injury with a tear of the
membranous urethra above the urogenital diaphragm
(UGD); partial or complete.
• Type 3: Combined anterior and posterior urethral injury
with the involvement of UGD; partial or complete.
• Type 4: Bladder neck injury with extension into the
urethra.
• Type 4a: Injury of the base of the bladder with periurethral extravasation.
• Type 5: Pure anterior urethral injury; partial or complete.
Way Question May BeAsked?
L. Michos
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
e-mail: lia.michos@jefferson.edu
A. Kohli (
Department of Surgery, Lankenau Medical Center,
Wynnewood, PA, USA
Division of Acute Care Surgery, Department of Surgery, Thomas
Jefferson University Hospital, Philadelphia, PA, USA
e-mail: anirudh.kohli@jefferson.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_88
*)
A 35-year-old female presents to the trauma bay after a bike
versus auto collision. She was struck from the side as the car
was traveling at about 50 mph. She was found about 10feet
from her bike and believed she lost consciousness. On
arrival at the trauma bay, the airway is intact, and bilateral
breath sounds are heard. Femoral pulses are 2+ bilaterally.
Vital signs are as follows: HR 122, BP 112/87, RR22, O2
saturation 98% on 6L nasal cannula. GCS 14 (1 point off
for confusion). Chest X-ray is within normal limits. The
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L. Michos and A. Kohli
abdominal X-ray is also within normal limits. The pelvic
X-ray does not show a pelvic fracture. FAST is inconclusive.
On a secondary survey, you nd that the abdomen is soft but
tender to palpation in the suprapubic region and lower
quadrants, there is blood at the urethral meatus, and the
patient has multiple bruises and lacerations/abrasions on
her extremities. She remains stable. What are your next
steps?
How toAnswer?
• As the patient is hemodynamically normal and has blood
at the meatus, one must consider a retrograde urethrogram (RUG) to rule out a urethral injury.
• The procedure involves injecting 20–30mL of diluted,
water-soluble contrast into the urethral meatus and then
obtaining an X-ray. A positive RUG study will demonstrate extravasation of contrast outside of the serpentine
cylinder of the urethral tract.
• As the FAST is inconclusive, RUG does not show contrast
extravasation, and the patient is stable so you may next
proceed to the CT scanner.
• Given the history provided and her ndings on the secondary survey, you proceed with a CT of the head, c-spine,
chest, abdomen, and pelvis. You also ask the CT tech to
perform a CT cystogram.
• If you nd an extraperitoneal bladder injury (Lewis
2023):
– Drain with a urinary catheter for 10–14days if there is
no bladder neck injury, concomitant rectal/vaginal
injury, or open pelvic fractures
• If you nd an intraperitoneal bladder injury (Lewis
2023):
– Always requires repair
– Debride devitalized tissue and close in two layers
using absorbable sutures—rst layer is mucosa and
muscularis, and the second layer is muscularis and
serosa
– Assess ureteral orices while the bladder is open
Alternate Scenario
A 35-year-old female presents to the trauma bay after GSW
to the lower abdomen. On arrival at the trauma bay, her
airway is intact, and she has bilateral breath sounds.
Femoral pulses are 2+ bilaterally. Vital signs are as follows:
HR 134, BP 92/56, RR26, O
rebreather. GCS 14 (1 point off for confusion). A cordis
catheter is placed and massive transfusion protocol is activated. On a secondary survey, you again see the bullet hole
in the right lower abdomen and another bullet hole in the
saturation 97% on a non-
2
right ank region. The patient is peritonitic on the exam.
What are your next steps?
How to Answer?
• You have two holes and no bullets seen in the body, and
the patient is unstable with peritoneal signs, so you should
proceed to the operating room.
• If the patient is protecting their airway, have anesthesia
intubate the patient in the OR in case the patient becomes
unstable.
• Prep the patient from chin to knees.
• Begin with an exploratory laparotomy. Communicate
with anesthesia prior to making the incision and throughout the case.
• What are the signs of renal injury?
– Hematuria is the most common sign. Can also have
ank pain, peritonitis, abdominal distention, or ecchymosis in the ank back or abdomen.
– The standard diagnostic tool for hemodynamically
stable patients is CT abdomen/pelvis with IV contrast
(Lewis 2023).
• What is the management of renal injuries by grade?
– Grades 1, 2, and 3: usually managed nonoperatively
with observation (Peitzman etal. 2020)
ICU monitoring with serial abdominal exams and
hemoglobins (Lewis 2023)
– Grade 4: depends if there is an injury to the renovascu-
lar pedicle or not (Peitzman etal. 2020)
If renovascular pedicle involved: may be able
to send to interventional radiology (IR) for
angioembolization (Lewis 2023; Peitzman etal.
2020)
If renovascular pedicle NOT involved: may be
able to observe the patient with bed rest and a repeat
CT scan in 48–72h (Peitzman etal. 2020)
– Grade 5: proceed to the OR
– Other indications for operative intervention include:
ureteropelvic avulsion, major vascular injuries, or urinary extravasation (Peitzman etal. 2020)
– Of course, if the patient is unstable, they require opera-
tive intervention
• What are the signs and how to diagnose bladder injury?
– lower abdominal/suprapubic pain, hematuria, inability
to pass urine, abdominal distension, perineal ecchymo-
ses (Lewis 2023)
– FAST or X-ray cystogram may be used (Lewis 2023)
– CT cystogram is very sensitive and specic and has
essentially replaced X-ray cystogram (Lewis 2023)
• What are the signs and how to diagnose ureteral injury?
– Hematuria
– Mechanism of injury—more likely to be penetrating
than blunt (Lewis 2023)