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Evaluation of Hematuria

Evaluation of Hematuria - Clinical Hub, References, Level I Adult Trauma Center Manual, Abdomen

Focus

Objective

Provide guidelines for the diagnosis and management of the trauma patient with hematuria.

Definitions

Gross hematuria: Blood in the urine that can be seen as a change in the urine color.

Microhematuria: Urine that appears normal but has tested positive for blood by either a dipstick technique or by microscopic examination.

Guidelines

  1. Treat the patient according to ATLS guidelines
  2. Determine the presence of blood by either inserting a Foley catheter or having the patient void spontaneously.
  3. If the urine has visible cells or is red or pink, then gross hematuria is present (usually > 50 RBC/HPF).
  4. If the urine appears normal but is “dipstick positive” for blood (1+ or greater) and has RBCs on microscopic exam (usually < 50 RBC/HPF), then microhematuria is present.
  5. For blunt trauma:
    1. For gross hematuria, determine whether there is a fractured pelvis and whether there is a mechanism or signs suggestive of an intra-abdominal injury.
      1. If there is a fractured pelvis, obtain an abdominal and pelvic CT scan and then consider a cystogram or CT cystogram
      2. In all other cases, obtain abdominal and pelvic CT
    2. For micro-hematuria, determine whether there is a mechanism or signs suggestive of an intra-abdominal injury.
      1. If there is a mechanism or signs suggestive of intra-abdominal injury, obtain an abdominal CT scan
      2. If there is no mechanism or signs suggestive of an intra-abdominal injury, then no further immediate diagnostic studies are necessary.
        1. If the patient is discharged, provide information about potential gross hematuria and have patient contact Trauma Team if hematuria is seen.
        2. If the patient is admitted, then obtain a urinalysis 24 hours after admission.  If has > 50 RBC/HPF, then obtain an abdominal CT scan.
  6. For penetrating trauma:
    1. If patient is unstable, go to OR for laparotomy.  Obtain intraoperative IVP if necessary.  This will demonstrate presence of bilateral kidneys.
    2. If patient is stable and has gross of microhematuria, obtain a “one-shot IVP.”
  7. Procedures:
    1. Cystogram (per Radiology):
      1. Place Foley catheter
      2. Obtain hypaque or renograin (full strength)
      3. Open a Toomey syringe and remove plunger. Attach barrel to the Foley catheter.
      4. Place 300 ml of contrast (10ml/kg in children) into bladder by gravity flow through the Foley catheter.
      5. Obtain pelvis film.
      6. Drain bladder.
      7. Obtain post-void films of pelvis.
    2. One-shop IVP
      1. Clamp Foley catheter if one has been placed (to obtain “free cystogram”).
      2. Administer intravenous injection of contrast (1ml/kg).
      3. Obtain abdominal film at 5 minutes after completion of contrast infusion.