Cloudy urine in trauma

[mobey]

I am not a urine expert.... or even amateur.

I was transporting a patient who had a fractured ankle, acute epigastric pain, and a minor head injury after a high speed collision. He was on a back board for approx. 4 hrs.

He was aggressive and combative and ETOH, so I was using fentanyl for pain, with occasional 1mg IVP of midazolam to keep him in a deep sedation.

He had good urine output (300ml/hr amber-clear) when suddenly, it turned super cloudy. I mean like freaking milk coming out of his bladder!

At the time I assumed it was myoglobin from being sedated on a board for such an extended period. After some research, I see myoglobin turns the urine dark redish. So what you all think? Renal injury? Acute bladder infection?

OK I'm reaching!

[J306]

According to the book "The Trauma Manual," cloudy urine in trauma situations where patients suffer sustaining crush injuries, severe extremity injuries (# ankle?), or vascular injuries are at risk for myoglobinuric ARF. It says these patients may have Rhabdomyolysis, and that the urine will present with a tea color when CPK is high. It goes on to say that "Cloudy urine that is dipstick positive for protein or blood, but without RBCs on microscopic examination, suggests Rhabdomyolysis."

http://books.google.ca/books?id=_Ik-V7DwCd8C&pg=PA365&lpg=PA365&dq=cloudy+urine+in+trauma&source=bl&ots=jXlIggWv2W&sig=GQIahvZexJIDsLABdWBswQJ0IWM&hl=en&sa=X&ei=7CBdUtfvCqSayQGCoIDwDw&ved=0CDYQ6AEwAg#v=onepage&q=cloudy%20urine%20in%20trauma&f=false

[ERDoc]

Did it look like actual white milk?

[island emt]

4 hours on a board?????

I am not a urine expert.... or even amateur.

I was transporting a patient who had a fractured ankle, acute epigastric pain, and a minor head injury after a high speed collision. He was on a back board for approx. 4 hrs.

Where you that far out in the sticks that the pt needed to be on the board that long?

First thought would be rhabdo from being on the board that long.

[mobey]

Yes ERDoc, looking closely at the tubing as it exits the urethra it looked like a white "fog". Almost seemed like a thick white fog that was mixing with the urine.

Island: that is the worst part of my job out here in remote Canada. People are boarded and can only be cleared via CT. The CT is 3hrs from my stn, add some scene time and delay at local hospital and people can easily spend 4-6hrs on a board. It is damaging to them and does no good at all..... But if I take them off the board I forfeit my registration # and get to start a new career.

I am VERY selective about who gets boarded, and we use NEXUS to clear a lot of people.

This is the system..... It sucks.

Nice find J306.

Rhabdo was definatly an issue whith this sedated (not moving) patient on a hard board.

I do try to tip the board periodically and move padding around the body to allow circulation to pressure points, but I know it's probably crap.

[ERDoc]

So you Canadians use the NEXUS rules, developed in the US and not the Canadian C-Spine Rules, interesting. As for the urine, it sounds like chyluria but good luck finding much about it.

[mobey]

To be clear we actually use a bit of a hybrid Canadian C-spine that also takes into account distracting injury and intoxication factors found in NEXUS.

I was just being simple in my post.

This is a written EMS protocol and I think the CCSR was just too open for interpretation to give to EMS practitioners without proper education.

[ERDoc]

It's okay Mobey, you can admit that we do things bigger and better.

[island emt]

I wasn't second guessing you Mobes.

Just commenting on how far out in the sticks you are.

We start worrying if our patients get to the hour mark while still boarded.

unfortunately they now have decided that All elderly fall patients don't meet the selective criteria & must be boarded. .

We also have selective spinal immobilization protocol that started 15 years ago with the wilderness medicine folks and later involved the NEXUS study.

One of the authors was our state medical director at the time.

[mobey]

Yes, anyone over 65 does not qualify for the exclusion according to either NEXUS or Canadian C-Spine, I don't recall off the top of my head.

That is the one time I will really push the limits though. I often contact OLMC to discuss a 'hybrid' type of SMR I enjoy using. I basically put on a collar and scoop them onto the cot. Keeping the cot flat, I use a blanket roll and tape to secure them to the frame of the cot. Then I move the straps on the cot to the criss-cross fasion, and bam...... Spinal motion restriction on a mattress!.

One way I get away with this if I call OLMC, 9 times out of 10 they will say "Why don't you just pad the board with blankets?", my standard answer is "Thin flannels don't really add padding as you can imagine, How about if I put the backboard under my cot mattress and use the 3" foam as padding"

By that time they get the point, and succumb to "Mobey's hybrid Selective Comfort Spinal Motion Restriction" (patent pending).

Edit for spelling

Edited October 16, 2013 by mobey