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Manual Of Definitive Surgical Trauma Care

Manual Of Definitive Surgical Trauma Care

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Published by: bovine splendor on Jul 10, 2013
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Bladder injuries are mainly the result of blunt trauma
and found in about 8 per cent of pelvic fractures.
Penetrating trauma is caused by gunshot, stabs, impale-
ment or iatrogenic injuries, mostly in relation to
orthopaedic pelvic fixation.

6.7.4.1INVESTIGATION

Signs and symptoms vary from inability to void and frank
haematuria, to vague abdominal or suprapubic tender-
ness without haematuria in a small percentage of cases.
Intraperitoneal injuries may be associated with a higher
serum creatinine and urea, and low sodium, but this bio-
chemical derangement takes some time to develop.
Ultrasonography and CT can be of use to demonstrate
free fluid in the abdomen, the presence of clots in the
bladder and a change in bladder filling and shape (with
sonar probe compression). CT cystogram can be done

as part of an abdominal CT study, and can differentiate
between intra- and extraperitoneal bladder injuries.
Retrograde cystography is the method of choice in the
emergency department, because it is very accurate as
long as a large enough volume of contrast (about
7mL/kg) is instilled, and at least two separate projec-
tions (anteroposterior and lateral views) are obtained.
Post-micturition films are essential.
Contrast extravasation will delineate loops of bowel
and the peritoneal contours in intraperitoneal ruptures,
although it will be tracking along the pelvic bones, scro-
tum, obturator areas, etc. in extraperitoneal ruptures.

6.7.4.2MANAGEMENT

Urgent operative treatment is indicated in all intraperi-
toneal, and some types of extraperitoneal injuries, while
others require delayed surgery upon failure of non-
operative methods. The majority of penetrating injuries
require immediate surgery.

Non-operative management

Urethral or suprapubic catheter drainage with a large
bore catheter, for up to 2 weeks, will allow most
extraperitoneal injuries from blunt trauma to heal;
surgery will be needed only if a cystogram at that stage
shows ongoing leakage. Contraindications to non-
operative management are bladder neck injury, presence
of bony fragments through the bladder wall, infected
urine and associated female genital injuries.
Extraperitoneal bladder repair during a laparotomy for
other trauma is often easily accomplished, but may be
dangerous if requiring opening into a tamponaded pelvic
haematoma, and inappropriate in the context of dam-
age control.

Operative management

Bladders can be repaired easily and with few complica-
tions with absorbable sutures.
All repairs should be carried out through an intraperi-
toneal approach, from within the lumen of the bladder,
after performing an adequate longitudinal incision on
the anterior surface in order to avoid entering lateral
pelvic haematomas.
The presence and patency of both ureteric orifices
must be confirmed in all cases. If suturing in the vicin-
ity, these should be cannulated with a size 5 feeding tube
or ureteric catheter.

The abdomen|141

In cases of gunshot wounds, wounds to the bladder
must be bothsought and identified. In some situations,
it will be necessary to open the bladder widely, explore
and repair from within.
Single layer mass suturing is indicated in extraperi-
toneal ruptures but for intraperitoneal ruptures closure
should be in separate layers.
A large-bore transurethral or suprapubic catheter, or
both, can be used, the latter being fed extraperitoneally
into the bladder, and a drain left in Retzius’s space. A
cystogram will be done in most cases after 10 days to 2
weeks, followed by removal of the suprapubic catheter.

6.7.4.3RECOMMENDED READING

Haas CA, Brown SL, Spirnak JP. Limitations of routine spiral
computerized tomography in the evaluation of bladder
trauma:J Urol1999;162:50–2.
Volpe MA, Pachter EM, Scalea TM, Macchia RJ, Mydlo JH. Is
there a difference in outcome when treating traumatic
intraperitoneal bladder rupture with or without a suprapubic
tube?J Urol1999;161:1103–5.

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