Overview of Genitourinary Trauma
Overview of Genitourinary Trauma
Genitourinary trauma is a common finding in the patient with multi-trauma, and includes injuries to the kidneys, bladder, ureters, urethra, penis, and scrotum. This article describes the care of the patient with genitourinary trauma focusing on assessments, diagnostic testing, and patient care. Nurses working with trauma patients need to monitor these patients carefully for genitourinary involvement because the signs and symptoms are not always clear.
Emergency departments (EDs) treat approximately 27.7 million patients per year for trauma in the United States (Pitts, Niska, Xu, & Burt, 2008). About 10% of all traumas primarily involve the genitourinary (GU) system, while another 10% to 15% of patients with abdominal trauma have concurrent GU injuries (Bent et al., 2008; Dandan & Farhat, 2009a, b; Lee, Oh, Rha, & Byun, 2007). The organs involved include the kidneys, bladder, ureters, urethra, penis, and scrotum. Female genital trauma is usually due to childbirth, female circumcision, or sexual assault; those topics are beyond the scope of this article. The purpose of this article is to examine the emergency care of patients presenting with GU trauma and males with genital trauma.
For any patient arriving in the ED, the first priority is assessing and stabilizing the ABCs – airway, breathing, and circulation – during the primary survey, along with maintaining cervical spine immobilization. The purpose of the primary survey is to identify and treat any life-threatening problems. These issues must be addressed definitively prior to assessing the rest of the patient's injuries in the secondary survey. During the patient's stay in the ED, the nurse must constantly re-assess the primary survey and act on any problems identified. The purpose of the secondary survey is to identify and treat all injuries (Galvin, 2005). See Table 1 for a description of the primary and secondary survey as it relates to the trauma nursing process.
Interventions designed to maintain patient airway and cervical spine, ensure optimal oxygenation, and restore or maintain adequate circulating volume are crucial. At the very least, trauma patients need cervical spine immobilization, high-flow oxygen, and two large-bore IVs with which to infuse either warmed crystalloids or blood products. Most seriously injured trauma patients will have either a nasogastric or orogastric tube to decompress the stomach. If there are no contraindications (such as blood at the urinary meatus or a displaced prostate), trauma patients also need a Foley catheter for hourly urine output measurements, cardiac monitoring, and continuous pulse oximetry. Maintaining normothermia is critical to prevent coagulopathies. Pain management is an important component of emergency nursing. The nurse should also prepare the patient for diagnostic testing and admission to the hospital if required (Campbell, 2007; Emergency Nurses Association [ENA], 2007; Galvin, 2005).
Patient history includes discovering the underlying mechanism of injury. There are two types of abdominal trauma: blunt and penetrating. Blunt trauma injuries result from force applied to the body without causing an open wound. Causes of blunt trauma include direct blows (sports injuries, violence), compression (industrial injuries, such as being trapped in machinery), or deceleration (motor vehicle crashes or falls from significant heights) (Campbell, 2007; ENA, 2007; MacDougal, 2005). Motor vehicle crashes cause the majority of abdominal trauma. Blunt abdominal trauma is usually not an isolated event; nurses caring for patients with abdominal trauma should be prepared to treat a multi-system trauma patient. Solid organs, such as the kidney, are prone to rupture after blunt trauma (MacDougal, 2005).
Penetrating trauma includes gunshot wounds, stabbings, and human or animal bites. While gunshot wounds can cause an immense amount of damage, abdominal stabbings often do not breach the peritoneal cavity, so mortality is lower than many would expect (MacDougal, 2005).
In general, care of the patient with GU trauma follows that of any trauma patient and requires astute, repetitive assessments. Signs and symptoms may be vague or confused with other conditions (Gervasini, 2007). The classic sign of renal trauma, hematuria, is absent in 5% to 36% of patients (Dandan & Farhat, 2009b; Lee et al., 2007; Rao et al., 2005). If present, hematuria can be frank (more than 50 red blood cells [RBCs] per high-powered field) or occult (MacDougall, 2005). Patients with any type of trauma may experience hypovolemic shock; those with pelvic fractures can lose massive amounts of blood (Gervasini, 2007). Nurses should constantly assess for shock and intervene as appropriate. Children do not exhibit hypotension until late in hypovolemic shock; nurses must maintain a high degree of suspicion for this in younger patients, including athletes who are often healthy and can compensate (Bernard, 2009).
All trauma patients should receive blood studies, including a complete blood count (CBC); type and crossmatch or type and screen; chemistry panel including glucose, electrolytes, and studies of renal function; urinalysis; pregnancy test in women of childbearing age; drug screens and alcohol level; and basic clotting studies (Galvin, 2005). Common imaging studies (see Table 2) include computerized tomography (CT); ultrasound (US); focused abdominal sonography for trauma (FAST) scan; diagnostic peritoneal lavage (DPL); cervical spine films (C-spine); abdominal, pelvic, or chest X-rays; arteriogram; cystogram; retrograde urethrogram; or intravenous pyelogram (IVP) (Lee et al., 2007; Master & McAninch, 2006; Rao et al., 2005). Death in patients with renal trauma is usually from hemorrhage or injury to other organ systems (MacDougal, 2005).
Abstract and Introduction
Abstract
Genitourinary trauma is a common finding in the patient with multi-trauma, and includes injuries to the kidneys, bladder, ureters, urethra, penis, and scrotum. This article describes the care of the patient with genitourinary trauma focusing on assessments, diagnostic testing, and patient care. Nurses working with trauma patients need to monitor these patients carefully for genitourinary involvement because the signs and symptoms are not always clear.
Introduction
Emergency departments (EDs) treat approximately 27.7 million patients per year for trauma in the United States (Pitts, Niska, Xu, & Burt, 2008). About 10% of all traumas primarily involve the genitourinary (GU) system, while another 10% to 15% of patients with abdominal trauma have concurrent GU injuries (Bent et al., 2008; Dandan & Farhat, 2009a, b; Lee, Oh, Rha, & Byun, 2007). The organs involved include the kidneys, bladder, ureters, urethra, penis, and scrotum. Female genital trauma is usually due to childbirth, female circumcision, or sexual assault; those topics are beyond the scope of this article. The purpose of this article is to examine the emergency care of patients presenting with GU trauma and males with genital trauma.
For any patient arriving in the ED, the first priority is assessing and stabilizing the ABCs – airway, breathing, and circulation – during the primary survey, along with maintaining cervical spine immobilization. The purpose of the primary survey is to identify and treat any life-threatening problems. These issues must be addressed definitively prior to assessing the rest of the patient's injuries in the secondary survey. During the patient's stay in the ED, the nurse must constantly re-assess the primary survey and act on any problems identified. The purpose of the secondary survey is to identify and treat all injuries (Galvin, 2005). See Table 1 for a description of the primary and secondary survey as it relates to the trauma nursing process.
Interventions designed to maintain patient airway and cervical spine, ensure optimal oxygenation, and restore or maintain adequate circulating volume are crucial. At the very least, trauma patients need cervical spine immobilization, high-flow oxygen, and two large-bore IVs with which to infuse either warmed crystalloids or blood products. Most seriously injured trauma patients will have either a nasogastric or orogastric tube to decompress the stomach. If there are no contraindications (such as blood at the urinary meatus or a displaced prostate), trauma patients also need a Foley catheter for hourly urine output measurements, cardiac monitoring, and continuous pulse oximetry. Maintaining normothermia is critical to prevent coagulopathies. Pain management is an important component of emergency nursing. The nurse should also prepare the patient for diagnostic testing and admission to the hospital if required (Campbell, 2007; Emergency Nurses Association [ENA], 2007; Galvin, 2005).
Patient history includes discovering the underlying mechanism of injury. There are two types of abdominal trauma: blunt and penetrating. Blunt trauma injuries result from force applied to the body without causing an open wound. Causes of blunt trauma include direct blows (sports injuries, violence), compression (industrial injuries, such as being trapped in machinery), or deceleration (motor vehicle crashes or falls from significant heights) (Campbell, 2007; ENA, 2007; MacDougal, 2005). Motor vehicle crashes cause the majority of abdominal trauma. Blunt abdominal trauma is usually not an isolated event; nurses caring for patients with abdominal trauma should be prepared to treat a multi-system trauma patient. Solid organs, such as the kidney, are prone to rupture after blunt trauma (MacDougal, 2005).
Penetrating trauma includes gunshot wounds, stabbings, and human or animal bites. While gunshot wounds can cause an immense amount of damage, abdominal stabbings often do not breach the peritoneal cavity, so mortality is lower than many would expect (MacDougal, 2005).
In general, care of the patient with GU trauma follows that of any trauma patient and requires astute, repetitive assessments. Signs and symptoms may be vague or confused with other conditions (Gervasini, 2007). The classic sign of renal trauma, hematuria, is absent in 5% to 36% of patients (Dandan & Farhat, 2009b; Lee et al., 2007; Rao et al., 2005). If present, hematuria can be frank (more than 50 red blood cells [RBCs] per high-powered field) or occult (MacDougall, 2005). Patients with any type of trauma may experience hypovolemic shock; those with pelvic fractures can lose massive amounts of blood (Gervasini, 2007). Nurses should constantly assess for shock and intervene as appropriate. Children do not exhibit hypotension until late in hypovolemic shock; nurses must maintain a high degree of suspicion for this in younger patients, including athletes who are often healthy and can compensate (Bernard, 2009).
All trauma patients should receive blood studies, including a complete blood count (CBC); type and crossmatch or type and screen; chemistry panel including glucose, electrolytes, and studies of renal function; urinalysis; pregnancy test in women of childbearing age; drug screens and alcohol level; and basic clotting studies (Galvin, 2005). Common imaging studies (see Table 2) include computerized tomography (CT); ultrasound (US); focused abdominal sonography for trauma (FAST) scan; diagnostic peritoneal lavage (DPL); cervical spine films (C-spine); abdominal, pelvic, or chest X-rays; arteriogram; cystogram; retrograde urethrogram; or intravenous pyelogram (IVP) (Lee et al., 2007; Master & McAninch, 2006; Rao et al., 2005). Death in patients with renal trauma is usually from hemorrhage or injury to other organ systems (MacDougal, 2005).
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