DRE in trauma patients?

[shaggybill]

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First, my apologies if this has been discussed before, but I couldn't find any previous threads on this topic.

I work in the ED as a tech, and a while back we had a male MVC trauma come in. As we were all doing our thing, one of the nurses started to put in a foley to get some urine and the doc stopped her and instructed her to never ever put in a foley prior to the rectal exam.

After it was all over, I asked the doc about that, and he said the DRE was to rule out urethral injury. Made sense, but I was curious so I went home and researched it. I found that this is an ACLS guideline, but further research showed several medical journal entries that stated this practice is all but useless for diagnosing acute injury, including urethral, spinal, etc.

So my questions is: is it important that a DRE is performed prior to foley insertion, or is this an antiquated practice? Also, although they take less than a minute to do, are DRE's even useful in a trauma situation?

 

[GeneralVeers]

So my questions is: is it important that a DRE is performed prior to foley insertion, or is this an antiquated practice? Also, although they take less than a minute to do, are DRE's even useful in a trauma situation?

They are only useful if you're suspecting spinal cord injury in an altered or unconscious patient. Poor rectal tone can indicate spinal cord injury. On the alert, conscious patient, with normal sensation and motor in his/her legs doing a DRE is invasive and unwarranted.

 

[Ian]

I'm still a 2nd year medical student so I have minimal clinical experience, but I was reading the chapter on Trauma in Schwartz's Surgery the other day and it said "Foley catheter placement should be deferred until urologic evaluation in patients with signs of urethral injury: blood at the meatus, perineal or scrotal hematomas, or a high-riding prostate." DRE was not specifically mentioned but how else would a high-riding prostate be evaluated? Like shaggybill, I'm also curious if DREs are done in trauma patient.

 

[alphaholic06]

I'm still a 2nd year medical student so I have minimal clinical experience, but I was reading the chapter on Trauma in Schwartz's Surgery the other day and it said "Foley catheter placement should be deferred until urologic evaluation in patients with signs of urethral injury: blood at the meatus, perineal or scrotal hematomas, or a high-riding prostate." DRE was not specifically mentioned but how else would a high-riding prostate be evaluated? Like shaggybill, I'm also curious if DREs are done in trauma patient.

Why are you reading Schwartz's as a 2nd year med student?

 

[RafaTech]

Why are you reading Schwartz's as a 2nd year med student?

Yeah, you should be reading First Aid instead...

 

[pinipig523]

So my questions is: is it important that a DRE is performed prior to foley insertion, or is this an antiquated practice? Also, although they take less than a minute to do, are DRE's even useful in a trauma situation?

Aside from spinal neuro check - the DRE is used to check for a high riding prostate which is indicative for a possible urethral injury which could be worsened by a foley.

 

[GeneralVeers]

Aside from spinal neuro check - the DRE is used to check for a high riding prostate which is indicative for a possible urethral injury which could be worsened by a foley.

Again, not useful on the alert, appropriate patient with no evidence of pelvic trauma.

 

[WilcoWorld]

Again, not useful on the alert, appropriate patient with no evidence of pelvic trauma.

But still useful in the multiply injured patient.

 

[GeneralVeers]

But still useful in the multiply injured patient.

I don't think so. A normal prostate doesn't rule out a urethral injury. A foley cath is very rarely life-saving. I'd get plane films of the pelvis, if there were significant fractures I'd hold off on a foley pending surgical evalm, or just get the retrograde urethrogram.

 

[deleted109597]

Not an ATLS rec anymore. And if they have a ureteral injury, the foley isn't going to make it that much worse.

I just wish nurses didn't feel the need to foley everyone before anything, including ACLS drugs or compressions.

 

[GeneralVeers]

Not an ATLS rec anymore. And if they have a ureteral injury, the foley isn't going to make it that much worse.

I just wish nurses didn't feel the need to foley everyone before anything, including ACLS drugs or compressions.

Both of these go into the "medical myths" from the other thread. I'm a big fan of not doing things, especially invasive things that will not change management. Rectal exams in almost every case are worthless.

The only time I do a rectal anymore is in patients with only complaint of rectal bleed and no visible external hemorrhoid.

 

[Rendar5]

has anyone ever felt a high riding prostate ever?

 

[Apollyon]

And if they have a ureteral injury, the foley isn't going to make it that much worse.

I don't know anything we could do that would worsen a ureteral injury (except maybe diuresis). I think (am sure) you meant "urethral".

 

[GeneralVeers]

has anyone ever felt a high riding prostate ever?

I don't feel enough prostates to know the difference. Even if it was high-riding, the chance I could detect it is zero.

 

[Birdstrike]

.

 

[deleted65604]

I don't feel enough prostates to know the difference. Even if it was high-riding, the chance I could detect it is zero.

I'm with you. My fingers are so short and stubby that I can hardly feel a prostate, let alone know whether it is "high-riding".

How much worse could a little tube make a torn urethra that was just shredded by sharp shards of bone crushed with thousands of pounds of force?

 

[pinipig523]

I don't know anything we could do that would worsen a ureteral injury (except maybe diuresis). I think (am sure) you meant "urethral".

We put percutaneous nephrostomies in the ER.

 

[Apollyon]

We put percutaneous nephrostomies in the ER.

I am missing the connection. Are you saying that, in cases of diagnosed ureteric injury, you guys place perc nephrostomies? Otherwise, I don't get it.

 

[deleted109597]

I don't know anything we could do that would worsen a ureteral injury (except maybe diuresis). I think (am sure) you meant "urethral".

You must not put them in as deeply as I do.

Or I shouldn't post in a hurry. Whichever works.

 

[TysonCook]

Not helpful for trauma (there was an article recently in Trauma as well as Annnals) for urethral injury. Only time we use it is for decreased LOC and any question of back trauma/neuro.

Lastly, there can be an argument for DRE with large pelvic fx's as well as against (colorectal injury vs bony shard cutting finger).

I'll post the articles when I get a chance.

 

[bougiecric]

A great review from Life in the Fast Lane.

 

[docB]

Not an ATLS rec anymore. And if they have a ureteral injury, the foley isn't going to make it that much worse.

I just wish nurses didn't feel the need to foley everyone before anything, including ACLS drugs or compressions.

This may start to change now that catheter related infection is a "NEVER" event 🙄 and the hospital won't get paid for it. Soon, I predict, it will take an act of Congress to get a foley into anyone, even those that need it.

Birdstrike's law of rectals:

There's only one reason that anyone else ever insists that you MUST do a rectal exam that seems to serve no apparent medical purpose whatsoever...

It's so they don't have to do it.

So true. There's a corollary to this rule that applies to academics: A physician is much more likely to be rigid in their belief that a certain exam always be performed on certain patients when "performing" said exam for them actually means ordering someone else to do it.

I learned that one from a professor who said that every female of child bearing age with abdominal pain must have a plevic as he sent me off to pelvicize the 48 yo F with RUQ pain, gallstones and elevated LFTs. "You need to rule out Fitz-Hugh-Curtis." BS. When has it ever been FHC?

 

[Hamhock]

xxx

 

[neusu]

DRE is for bulbocavernosus reflex in spinal cord injury patients

 

[Apollyon]

DRE is for bulbocavernosus reflex in spinal cord injury patients

And do you squeeze the penis or pull on the Foley, too?

 

[Birdstrike]

.

 

[neusu]

And do you squeeze the penis or pull on the Foley, too?

Yes, if the patient has one. It's the best test to determine whether a SCI is complete, incomplete or equivocal.

 

[docB]

The answer is obvious, docB, the one time you don't do the pelvic...

😀

So true. It's like the Heisenberg Principle, by looking I make it disappear.

 

[Apollyon]

Yes, if the patient has one. It's the best test to determine whether a SCI is complete, incomplete or equivocal.

Has one what? A penis or a Foley? Only 70% of normal women even have a bulbocavernosus reflex (normal meaning uninjured and not malformed).

You do realize that you're not teaching almost anyone here anything, right? Like, we already know this stuff. You get that, right? The way you write is like you are a lecturer teaching something.

Oh, wait - you CAN teach me something - how do you differentiate between "incomplete" and "equivocal"?

 

[neusu]

Has one what? A penis or a Foley? Only 70% of normal women even have a bulbocavernosus reflex (normal meaning uninjured and not malformed).

Either/or

You do realize that you're not teaching almost anyone here anything, right? Like, we already know this stuff. You get that, right? The way you write is like you are a lecturer teaching something.

Merely stating my practice preferences. FWIW, 98% of males and 81% of females have a bulbocavernosis reflex (http://www.ncbi.nlm.nih.gov/pubmed/7265365) . Also, 80% of spinal cord injuries occur in males (http://www.fscip.org/facts.htm). That means, in a population that is 50% male and 50% female, 9 out of 10 people have a bulbocavernosis (5/5 males and 4/5 females) and for arguements sake of the 20% of SCI that occur in female, only 20% lack bulbocavernosis. Thus, in the population of patients who present with spinal cord injury, only 4% will lack bulbocavernosis physiologically.

Oh, wait - you CAN teach me something - how do you differentiate between "incomplete" and "equivocal"?

Incomplete injury is where there remains a motor or sensory function distal to the level of injury. Equivocal is where there is no motor or sensory function and the bulbocavernosis reflex is absent. Complete is where there is no motor or sensory function and the reflex has returned.

 

[Ian]

Why are you reading Schwartz's as a 2nd year med student?

I'm not from the US. We read the first couple of chapters (general considerations) in Schwartz in our Surgery 1 class. In third year we read the subsequent chapters (specific considerations).

 

[Birdstrike]

.

 

[Docgeorge]

has anyone ever felt a high riding prostate ever?

Yes i've found high riding prostates. I routinely do DRE on my adult trauma patients that alerts or priorities (these patients are not usually alert or conscious).

 

[deleted65604]

You could make the same argument for 90% of physical exam findings, labs, or historical questions. For example, when was the last time cardiac auscultation truly changed your disposition. Should I freak out if my chest pain patient has a new murmur when their vitals are decent? Should I be comforted by a lack of a murmur in an IV drug abuser when they have fever without a source?

Most of what we do in the history and physical and laboratory work-up has a low yield. If you ask 30 questions on history and perform 30 points of cumulative examination (visual inspection, palpation, auscultation) of the respective 10 or so body systems, you have a massive number of data points (double the number of data points for a complete neuro-exam).

Because there is such a high number of data points, there are a massive number of false positives and false negatives that we deal with, making the accuracy of any given test, historical question, or physical exam very low.

However, we are here to rule out emergencies. If I miss 1/1000 emergencies, I will quickly be out a job. Sometimes to rule out emergencies (at least to make the chart pretty for lawyers), I need those 200 data points that all point in a positive direction.

 

[Birdstrike]

.

 

[deleted65604]

Surely you can't be forgetting the #1 reason to do a 8+ system exam? So your level 5's don't get downgraded to level 3's. 🙂

Great point. Usually the ONLY reason. Because CMS makes us to get paid.