Step 2 CK question

[ResidentCan]

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Hi guys,

Question from Step II CK Usmle booklet.

An 18-year-old man is brought to the emergency department 45 minutes after his car slid off an icy road into a
telephone pole at approximately 35 miles per hour. He was the restrained driver, and the air bag inflated. Examination
shows multiple contusions over the chest bilaterally; there is tenderness to palpation over the right lower chest wall.
The abdomen is flat, soft, and nontender. A complete blood count and serum concentrations of electrolytes, urea
nitrogen, and creatinine are within the reference range. Toxicology screening is negative. His urine is pink; urinalysis
shows 80 RBC/hpf but no WBCs. Which of the following is the most appropriate next step in management?
(A) CT scan of the abdomen and pelvis with contrast
(B) Magnetic resonance arteriography of the renal arteries
(C) Intravenous administration of antibiotics
(D) Exploratory laparotomy
(E) No further studies are indicated


Answer is A.

Any ideas? I thought it would be E.

 

[Houmd]

Hi guys,

Question from Step II CK Usmle booklet.

An 18-year-old man is brought to the emergency department 45 minutes after his car slid off an icy road into a
telephone pole at approximately 35 miles per hour. He was the restrained driver, and the air bag inflated. Examination
shows multiple contusions over the chest bilaterally; there is tenderness to palpation over the right lower chest wall.
The abdomen is flat, soft, and nontender. A complete blood count and serum concentrations of electrolytes, urea
nitrogen, and creatinine are within the reference range. Toxicology screening is negative. His urine is pink; urinalysis
shows 80 RBC/hpf but no WBCs. Which of the following is the most appropriate next step in management?
(A) CT scan of the abdomen and pelvis with contrast
(B) Magnetic resonance arteriography of the renal arteries
(C) Intravenous administration of antibiotics
(D) Exploratory laparotomy
(E) No further studies are indicated


Answer is A.

Any ideas? I thought it would be E.

Standard of care when there is an abdominal bleed or pelvic bleed to conduct a CT with contrast to identify where the blood is coming from.

 

[DrMattOglesby]

if the patient is pissing blood (meaning that his kidneys are potentially compromised), then is it still permissible to use IV contrast?

Don't acute abdominopelvic bleeds "light up" on CT anyway? Or is that just for acute cranial bleeds?

 

[CDI]

if the patient is pissing blood (meaning that his kidneys are potentially compromised), then is it still permissible to use IV contrast?

Don't acute abdominopelvic bleeds "light up" on CT anyway? Or is that just for acute cranial bleeds?

if the patient is pissing blood (meaning that his kidneys are potentially compromised), then is it still permissible to use IV contrast?

Don't acute abdominopelvic bleeds "light up" on CT anyway? Or is that just for acute cranial bleeds?

I guess its a matter of degree? Either save his life (catch the internal bleed) or save his kidneys (and possibly missing the bleed).

See here for better explanation on indications of Contrast CT: http://forums.studentdoctor.net/showpost.php?p=6008408&postcount=4

 

[Ronin786]

if the patient is pissing blood (meaning that his kidneys are potentially compromised), then is it still permissible to use IV contrast?

Don't acute abdominopelvic bleeds "light up" on CT anyway? Or is that just for acute cranial bleeds?

I don't believe renal failure is a contraindication to contrast use. Its a risk/benefit thing, and in a case like this, the benefit far outweighs the risk.

There are two main contraindications for the administration of iodinated IV contrast: contrast induced nephropathy and allergy to iodinated contrast. Current policy suggests a creatinine of less than or equal to 1.5 mg/dl and no evidence of acute kidney injury for IV contrast administration. The attending ER Radiologist and the referring clinician may allow for patients with mild renal failure to receive intravenous contrast when the risks are felt to be outweighed by the benefits The Department of Radiology's policies allow patients who have had a severe anaphylactoid reaction to receive IV contrast if the ER attending believes the study is needed emergently and the patient receives premedication (http://radiology.yale.edu/patientcare/policies/premedication.aspx). Patients who only have one kidney or are kidney transplant recipients can still receive IV contrast; per departmental policy, the volume of contrast will be decreased (http://radiology.yale.edu/patientcare/policies/singlekidney.aspx). Departmental policy states that patients taking Glucophage (Metformin) should have the medication withheld for 48 hours following contrast administration and should have their renal function re-tested prior to re-starting (http://radiology.yale.edu/patientcare/policies/glucophage.aspx).

http://radiology.yale.edu/patientcare/physicians/er/contrastquestions.aspx

CT with intravenous contrast is the gold standard for radiographic diagnosis of stable patients with suspected renal injuries. CT can define the location of the injury, identify renal contusions and devitalized segments, and allow visualization of the entire retroperitoneum and abdominal organs. A pedicle injury is diagnosed by a lack of contrast enhancement of the kidney (Figure 1) or a central parahilar hematoma. A large medial hematoma displacing the renal vasculature suggests a venous injury. CT angiography provides assessment of the renal vasculature. Images taken at a 10-15 min delay will allow visualization of the renal collecting system and diagnosis of renal pelvis and ureteral injuries. Renal pelvis injuries may be indicated by contrast extravasation just medial to the renal hilum (Figure 2).

http://www.medscape.org/viewarticle/727952_2

Even with renal failure, I've always been taught/learned that you use IV contrast but insure that there is adequate hydration at all times.

 

[futuredoctor10]

In this scenario, I think it makes sense with risk/benefit, it is way more important to give contrast and determine if there is an internal bleed.

Even with renal failure, I've always been taught/learned that you use IV contrast but insure that there is adequate hydration at all times.

Interesting. Anyone have more comment on this? In my experience, it seems like IV contrast is avoided like the plague if at all possible in patients with renal problems?