What is the primary concern for an older adult patient presenting with flank ecchymosis, pain, and gross hematuria after a fall, striking their right flank 48 hours ago?

Primary Concern: Urinary Tract Injury (Answer: B)

The AGACNP should be most concerned about urinary tract injury, specifically renal trauma, given the classic triad of flank trauma mechanism, flank ecchymosis, and gross hematuria. This presentation demands immediate imaging evaluation regardless of hemodynamic status.

Why Urinary Tract Injury is the Priority

The clinical presentation is pathognomonic for renal injury:

• Flank ecchymosis is a specific sign of renal trauma and indicates significant force transmission to the retroperitoneum 1
• Gross hematuria occurs in 77-100% of bladder injuries and is the hallmark of significant urinary tract trauma 1, 2
• The mechanism (fall with direct flank impact) represents a deceleration injury, which makes the kidney particularly vulnerable since it is fixed only by the renal pelvis and vascular pedicle 1
• The 48-hour delay in presentation increases risk for complications including ongoing bleeding, urinoma formation, or missed high-grade injuries 1

Immediate Diagnostic Approach

Obtain IV contrast-enhanced CT of abdomen/pelvis with immediate and delayed phases to evaluate for renal laceration, collecting system injury, and urinary extravasation 1. This is the standard of care even in hemodynamically stable patients when:

• Gross hematuria is present (regardless of blood pressure) 1
• Physical exam findings suggest renal injury (flank ecchymosis, rib fractures, significant flank blow) 1
• Mechanism involves rapid deceleration or significant flank trauma 1

Do not rely on degree of hematuria alone to exclude significant injury - up to 29% of grade 2-4 renal injuries can present without gross hematuria, and 20.8% may have no hematuria at all 3. The combination of mechanism, flank ecchymosis, and gross hematuria mandates imaging 1.

Why Other Options Are Less Concerning

Traumatic Brain Injury (Option A)

While falls can cause head trauma, this patient has no reported head strike, no neurological symptoms mentioned, and the dominant clinical findings localize to the flank/urinary system 1. The 48-hour delay with ability to present from home makes clinically significant TBI unlikely.

Rib Fractures (Option C)

Though rib fractures are associated with renal injury 1, they are:

• A marker of injury severity rather than the primary concern
• Less immediately life-threatening than potential renal vascular injury or ongoing hemorrhage
• Would be identified on the same CT scan obtained for renal evaluation 1

Delirium (Option D)

Delirium is not suggested by this presentation - the patient successfully sought care 48 hours post-injury and provided a coherent history. While older adults are at risk for delirium, there are no cognitive symptoms described, and this would not explain the gross hematuria and flank findings.

Critical Management Considerations

Assess hemodynamic stability immediately - systolic BP <90 mmHg or signs of shock require immediate intervention (surgery or angioembolization) rather than prolonged imaging 1. However, stable patients with this presentation should undergo non-invasive management initially 1.

The kidney is the most commonly injured genitourinary organ, accounting for up to 5% of trauma victims and 24% of traumatic abdominal solid organ injuries 1. In older adults with falls, up to 34% of multisystem trauma patients may have renal injury despite absence of shock 1.

Follow-up imaging is mandatory for this patient given the delayed presentation - patients with deep lacerations (AAST Grade IV-V) or clinical signs of complications (fever, worsening flank pain, ongoing blood loss, abdominal distention) require repeat CT imaging 1.

Common Pitfalls to Avoid

• Do not dismiss gross hematuria as minor trauma - this represents significant urinary tract injury until proven otherwise 1
• Do not delay imaging based on hemodynamic stability alone - mechanism and physical findings (flank ecchymosis) mandate evaluation even in stable patients 1
• Do not attribute findings to age-related fragility without investigation - older adults can have significant renal injuries with seemingly minor mechanisms 1
• Do not forget delayed imaging - complications like urinoma, infection, or ongoing bleeding may develop days after initial injury 1