Rosen & Barkin's 5-Minute Emergency Medicine Consult (106 page)

• In children, the bladder is an intra-abdominal organ and descends into the pelvis by age 20 yr.
  
• Intraperitoneal rupture is more common in children than adults because the bladder is an abdominal organ.
  
• Bladder injury is more common in children than in adults because the pediatric bony pelvis is less rigid and transmits more force to adjacent structures.
  

DIAGNOSIS

Triad:

• Gross hematuria
  
• Suprapubic pain
  
• Difficulty voiding
  

Establish potential mechanism.

Evaluate urethral meatus—if blood is present, do not insert Foley catheter until retrograde urethrogram (RUG) is performed (concomitant urethral and bladder injuries occur in 10–29% of patients).

• History of trauma or procedures
  
• Evaluate urethral meatus for blood.
  
• Urinalysis (UA)
  
• Retrograde cystography
  

• UA:
  
  • Gross hematuria in 95–100% of patients with significant bladder or urethral trauma
    
  • Microscopic hematuria in 5%
    
• BUN and creatinine:
  
  • The BUN can be elevated from resorption of urine within the peritoneum.
    
• Electrolytes:
  
  • Hyperkalemia and hypernatremia may result from resorption of urine within the peritoneum.
    

• Retrograde cystography and retrograde CT cystography are the methods of choice to diagnose a ruptured bladder. Both studies have reported sensitivity and specificity of 95% and 100% respectively.
  
• If urethral injury is suspected, the cystogram is performed after a RUG.
  
• Cystography technique:
  
  • Kidneys/ureter/bladder (KUB) scout film
    
  • Infuse 100 mL of diluted contrast via Foley into bladder. Contrast material needs to be diluted: 30% or 6:1 saline; otherwise it is too dense.
    
  • Plain film is repeated to evaluate early extravasation.
    
  • If initial film is normal, fill rest of bladder with diluted contrast:
    
    • Min. 300–350 mL total for adult
      
    • 3–5 mL/kg or 60 mL + (age in yr × 30) for children or until discomfort
      
  • It is essential to have a bladder full of contrast for diagnosis; it is not sufficient to place contrast and clamp Foley in antegrade fashion.
    
  • Cystogram films taken in AP, lateral, and oblique views (oblique may be difficult in trauma and CT is often used)
    
  • Empty bladder and obtain a postdrainage film unless CT cystography obtained.
    
  • Postdrainage film is essential without CT cystography—10% of bladder ruptures are seen only on postdrainage film; a distended bladder may hide extravasation.
    
• Cystography interpretation:
  
  • Extraperitoneal rupture: Tear drop- or star-shaped form
    
  • Intraperitoneal rupture: Outlining of bowel or contrast within the paracolic gutters
    

• FAST scan:
  
  • Free pelvic fluid should raise concern for bladder injury.
    

• Peritoneal trauma
  
• Urethral trauma
  
• Renal or ureteric trauma
  

TREATMENT

Do not attempt bladder catheterization in the field.

• ABCs
  
• Early urologic consultation
  

• Urologic consultation is needed when bladder rupture is diagnosed.
  
• Extraperitoneal nonpenetrating ruptures may be managed by catheter drainage:
  
  • 20F Foley or larger for 14 days
    
  • 80% of lacerations will seal in 3 wk.
    
  • If patient is undergoing abdominal or pelvic surgery for other injury, surgical repair is recommended.
    
• Intraperitoneal ruptures require surgical exploration.
  
• Bladder contusions do not need any specific interventions.
  

Broad-spectrum antibiotics for intraperitoneal rupture

FOLLOW-UP

• Concurrent major trauma requiring admission or observation
  
• Surgical intervention required
  

• Bladder contusion with no rupture or other major trauma requiring admission
  
• Most cases of bladder rupture will require admission; discharge only after clearance by urology and no other associated injuries.
  

Any bladder injury managed as an outpatient should have urologic referral.

Follow-up to be arranged with urology:

• Extraperitoneal bladder rupture with Foley catheter management will have Foley removal in 14 days.
  

• Any free fluid on CT or US exam should raise suspicion for bladder injury.
  
• Unresponsive, altered, and intoxicated patients warrant careful exam.
  
• Penetrating injuries to lower abdomen with any degree of hematuria warrant cystography.
  

• Marx JA, Hockberger RS, Walls RM, et al., eds.
  Rosen’s Emergency Medicine Concepts and Clinical Practice
  . 8th ed. St. Louis, MO: Mosby; 2013.
  
• Ramchadani P, Buckler PM. Imaging of genitourinary trauma.
  AJR Am J Roentgenol
  . 2009;192(6):1514–1523.
  
• Uptodate.com
  
• Wein AJ, Kavoussi LR, Novick AC, et al., eds.
  Cambell-Walsh Urology
  . 10th ed. Philadelphia, PA: WB Saunders; 2012.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Pelvic Fracture
  
• Urethral Trauma
  
• Trauma, Multiple
  

CODES

• 665.50 Other injury to pelvic organs, unspecified as to episode of care or not applicable
  
• 867.0 Injury to bladder and urethra, without mention of open wound into cavity
  
• 867.1 Injury to bladder and urethra, with open wound into cavity
  

BASICS

• Defined as an orbital floor fracture without orbital rim involvement
  
• Results from sudden blunt trauma to the globe:
  
  • Typically caused by the force of a projectile > half the size of the fist
    
• Force transmitted through the noncompressible structures of the globe to the weakest structural point: The orbital floor
  
• Transmitted force “blows out” or fractures the orbital floor.
  
• Orbital floor serves as roof to air-filled maxillary and ethmoid sinuses:
  
  • Communication between the spaces results in orbital emphysema.
    
• Orbit contains fat, which holds the globe in place:
  
  • Orbital floor fracture may result in herniation of the fat on the inferior orbital surface into the maxillary or ethmoid sinuses.
    
  • Leads to enophthalmos owing to orbital volume loss and sinus congestion; fluid collection may occur secondary to edema and bleeding.
    
• Infraorbital nerve runs through the bony canal 3 mm below the orbital floor:
  
  • Injury may result in hypoesthesia of the ipsilateral cheek and upper lip.
    
  • To distinguish facial hypoesthesia related to local swelling from nerve injury: Test for sensation on the ipsilateral gingiva, which is within the infraorbital nerve distribution.
    
• Inferior rectus and the inferior oblique muscle run along the orbital floor:
  
  • Restriction of these extraocular muscles may occur because of entrapment within the fracture, contusion, or cranial nerve dysfunction.
    
  • Typically manifests as diplopia on upward gaze
    
  • Inability to elevate the affected eye normally on exam
    
• Medial rectus located above the ethmoid sinus:
  
  • Less commonly entrapped
    
  • Diplopia on ipsilateral lateral gaze