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Education Newsletter

Offered by the PTS Education Committee

Case Report Topic:
Penetrating Trauma

Prepared by: Roberta Miller, RN, MSN, CON, CPEN, TCRN

Patient was a transfer from an outlying facility:

Transfer report:

Patient was transferred via POV. Transfer with report of broken stool leg in rectum. Patient was transported to outside hospital at 2200 by local EMS after falling off a stool and landing on the broken leg.
Vital Signs: BP 142/72 HR 94 RR 18 02 Sat: 98% T 37.1 C

Emergency Department Arrival:

Arrival at 2354. Patient is a 15 year old male, who reports he was spinning around on a bar stool. The leg of the bar stool broke and the sharp end penetrated the rectal area. Reports bleeding from rectum and penis. Time of triage: 0010 Vital Signs: BP 120/80 HR 98 RR 18 02 Sat: 99% T 37.1 C

Emergency Department Course:

The staff questioned the mechanism of injury. No trauma activation was made for the patient. Initial physician assessment at 0018 of the patient revealed penetration to the rectal area with skin disruption and bleeding from the rectal area and penis. At 0023, the trauma surgeon was consulted and ordered CT, IV, oral contrast and to consult urology. Antibiotics were initiated at 01:43. Due to a delay in completing the oral contrast, the CT was completed at 0610.

Findings: Large prostate laceration with urethral laceration and bladder injury with extravasation of contrast with need for diverting colostomy due to bowel injury.

Patient diagnoses include:
Bladder rupture
Prostate lac involving urethra
Rectum lac - perforation; full thickness
Urethra lac - partial thickness

0818 Patient transfer to OR

Hospital Course:

Admitted to surgery for diverting colostomy then admitted to inpatient floor under the care of trauma services and urology services to consult. The genitourinary injury was retroperitoneal, non-operable and treated with a urinary catheter. The patient was evaluated for possible sexual abuse during the hospital stay to confirm the mechanism of injury. Patient experienced no complications throughout the hospital stay, the urinary catheter was removed on day 3, and the patient was discharged home on day 5 with follow up in the surgery urology clinics

After discharge:

The patient healed well and returned 4 months later for colostomy closure.

Topic Review: Penetrating Trauma to Rectum:

Penetrating trauma to the rectal area can cause extensive internal injuries and should receive rapid evaluation. High-velocity trauma, such as gunshot wounds, to buttocks can result in extraperitioneal rectal trauma, intraperitoneal injuries, spinal injury, visceral injuries, vascular injuries, or other life-threatening injuries (Hefny et al., 2013). However, low-velocity penetrating injuries most commonly result in extraperitoneal rectal trauma. Standard recommendations for management of rectal trauma are fecal diversion, distal rectal washout, presacral drainage and repair of the rectal injury when possible (Melland-Smith et al., 2020). However, accurate assessment of the injury, irrigation, and closure of closure of extraperitoneal recta injuries may help avoid the use of a diverting stoma (Melland-Smith et al., 2020).

Limited research exists exploring penetrating trauma to the rectum in pediatric patients. The most common cause of penetrating rectal injury in pediatric patients is sexual abuse, and accidental impalement is the second leading cause. A thorough and accurate history of the mechanism of injury is critical.

Initially, all patients with penetrating injury to the rectum should be treated according to the Advanced Trauma Life Support (ATLS) principles. Trauma patients must be stabilized before examination of the rectal injuries. Abdominal examination is essential to determine areas of injury, potential penetration or bleeding sites, and possible organ injuries (Ahern et al., 2017). The key factor in successful management of the injury is early identification of injuries. Early treatment decreases the risk of infection or other complications. The standard treatment is primary repair, which evidence shows results in better outcomes and fewer complications (Ahem et al., 2017). Management should be individualized to the patient based on extent of injury and evaluation findings.

References

Ahern, D. P., Kelly, M. E., Courtney, D., Rausa, E., & Winter, D. C. (2017). The management of
penetrating rectal and anal trauma: A systematic review. Injury, 48(6), 1133-1138.
https://pubmed.ncbi.nlm.nih.gov/28292518/

Hefny, A. F., Salim, E. A., Bashir, M. O., & Abu-Zidan, F. M. (2013). An unusual stab wound to the
buttock. Journal of emergencies, trauma, and shock, 6(4), 298-300.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3841542/

Melland-Smith, M., Chesney,T., Ashamalla, S., & Brenneman, F. (2020). Minimally
invasive approach to low-velocity penetrating extraperitoneal rectal trauma. Trauma Surgery &
Acute Care Open, 5(1). https://tsaco.bmj.com/content/5/1/e000396


CME Opportunitues

Evaluation and management of pediatric patients with penetrating trauma to the torso. The course reviews the principles of ballistics, anatomical and physiological considerations of the pediatric patient, and recommendations for management.

CME/CNE Link

Accident or injury in pediatric patients. The activity addresses obtaining an accurate history, ordering appropriate studies, performing a comprehensive exam, differentiating between accidental and intentional injuries, and documentation.

CME/CNE Link