Trauma center

2014 Top Stories in Urology: AUA Urotrauma Guidelines

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Practicing urologists have always played an integral role in the evaluation and treatment of acute genitourinary organ injury. Well-established criteria for imaging of blunt trauma, originally pioneered by McAninch and colleagues, have been incorporated in most trauma center protocols. Although trauma surgeons may manage life-threatening renal hemorrhage with nephrectomy, urologist input remains critical when deciding appropriate intervention for all other urinary tract and genital injuries.

The field of genitourinary trauma and reconstruction received a major push toward dissemination of evidence-based best practices with the introduction of the AUA Guideline on Urotrauma.1 Guidelines drive education, policy, and changes in practice patterns that may be adopted worldwide. In addition, gaps in knowledge identified by the evidence review define opportunities for future research.

Urologists can expect two diverging outcomes of the introduction of guidelines. Trauma systems will look to the guidelines to ensure adherence with evidence-based recommendations. This will likely create greater demand for urological consultation and involvement during and after hospitalization. Conversely, if urologists are not willing to provide prompt engagement and collaboration with trauma teams, it is possible that other practitioners will take over decision-making and care of patients with genitourinary injuries.

Key takeaways from the AUA Urotrauma Guidelines include the following:

  1. The surgical team must perform immediate surgery (or angioembolization in selected situations) in hemodynamically unstable patients with no or transient response to resuscitation.
  2. Follow-up imaging is necessary for high-grade renal injuries, although the particular lesions and how to follow them remains unknown.
  3. Ureteral injury should be explored and repaired immediately; if diagnosis is delayed, use a drain-and-wait approach.
  4. Intraperitoneal bladder rupture should always be repaired after blunt trauma.
  5. Extraperitoneal bladder rupture can be classified into complicated and uncomplicated. Complicated injuries require exploration and repair, whereas uncomplicated injuries can be managed with catheter drainage.
  6. Suprapubic tubes may be used in the face of orthopedic hardware as determined by expert opinion; it must be acknowledged that there is little evidence to support the guideline recommendation.
  7. Primary urethral realignment is an option for pelvic fracture urethral injury. Suprapubic cystostomy is almost always the best initial choice for urinary drainage in the acute setting of a pelvic fracture urethral injury. Primary realignment will reduce stricture rates, but prolonged efforts at realignment should be avoided.
  8. Genital injuries require early exploration using correct approaches at the local hospital level based on the mechanism and severity of injury. An exception to this is penile replantation, which should be referred to centers of excellence for microvascular repair.

Reducing trauma deaths in the UK.

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Traumatic haemorrhage is a leading cause of death in young adults in the UK.1 The CRASH-2 trial showed that the early administration of tranexamic acid safely reduces mortality in bleeding trauma patients.2 Further study demonstrated that the treatment is widely practicable and cost effective.3

RoadPeace—the UK national charity for road crash victims—represented trauma victims on the CRASH-2 trial steering committee, and we are now committed to ensuring that victims benefit from this life-saving treatment. To assess whether bleeding trauma patients in the UK are treated with tranexamic acid, we sent freedom of information requests to 291 UK hospitals in September, 2012, which asked the following questions: does your hospital’s trauma protocol include administration of tranexamic acid to bleeding trauma patients; and in 2011, how many acute trauma patients received a blood transfusion and, of those, how many were treated with tranexamic acid?

209 (72%) of the 291 hospitals responded. Of these 209 hospitals, 11 stated that they did not treat trauma patients and 19 failed to answer the question about trauma protocols. Of the 179 remaining hospitals, 159 (89%) include tranexamic acid in their trauma protocols. The second question aimed to assess whether bleeding trauma patients received tranexamic acid. Most hospitals did not answer this question (citing the pertinent Freedom of Information Act 2000 clause) on the basis that it would be too costly to obtain the data. 34 hospitals reported the number of trauma patients that received a blood transfusion and the number given tranexamic acid. Of 451 trauma patients transfused at these 34 hospitals, 34 (8%) received tranexamic acid. Four of these 34 hospitals were major trauma centres. Of 285 trauma patients transfused at these four major trauma centres, 13 (5%) received tranexamic acid.

Although tranexamic acid is included in most hospital trauma protocols, our data show that few bleeding trauma patients were given this treatment in 2011. Patients with trauma severe enough to require blood transfusion would be expected to benefit from tranexamic acid, and we are concerned that patients were denied this life-saving treatment. One explanation for the low use is that tranexamic acid might not have been incorporated into trauma protocols for the full duration of 2011. Since most hospitals now include tranexamic acid in their trauma protocols, more recent figures might be higher.

We will repeat this survey in 2013 to assess progress. We are optimistic that use will improve because of recent and rapid policy responses—notably, the aforementioned trauma protocol coverage, the Trauma Promise, and the NHS move to include tranexamic acid administration in its 2013—14 best practice tariff for major trauma centres.4, 5 To support these efforts, we recommend that tranexamic acid be included in trauma audit at all UK accident and emergency hospitals and that hospitals regularly publish data on the proportion of trauma patients that are appropriately given the treatment. We urge all UK hospitals to reaffirm their commitment to providing effective trauma care by making the Trauma Promise.

Source: Lancet