Archives of Academic Emergency Medicine. 2019; 7 (1): e64 OR I G I N A L RE S E A RC H Association of Clinical Signs and Symptoms with Abnor- mal Urinalysis Findings of Blunt Trauma Patients; a Cross- Sectional Study Bahram Zarmehri1, Ayeh Shouman1, Elham Pishbin1, Niaz-Mohammad Jafari Chokan1, Mona Najaf Najafi2, Seyed Reza Habibzadeh1, Esmaeil Rayat Dost3, Mahdi Foroughian1∗ 1. Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran. 2. Clinical Research Unit, Mashhad University of Medical Sciences, Mashhad, Iran. 3. Department of Emergency Medicine, Jahrom University of Medical sciences, Jahrom, Iran. Received: August 2019; Accepted: October 2019; Published online: 11 November 2019 Abstract: Introduction: Urinalysis (UA) is performed routinely as a diagnostic screening test for trauma patients in most centers. This study aimed to examine the relationship between patients’ clinical signs and symptoms with UA findings. Methods: This cross-sectional study was carried out on multiple trauma patients between 18 to 65 years old, who were referred to the Emergency Department. UA was performed for all patients and its associa- tion with clinical signs and symptoms (pain, tenderness, abrasion, ecchymosis, hematoma, etc.) in abdomen, back, flank, and inferior hemi-thorax was evaluated. Results: 640 patients with the mean age of 39.8 ± 11.2 years were studied (65.0% males). 271 (42.4%) cases had associated injuries and 554 (86.6%) cases had at least one sign or symptom of trauma in abdomen, back, flank or inferior hemi-thorax. 146 (22.8%) patients had negative UA. Among cases with positive UA, 364 (56.9%) cases had microscopic hematuria with RBC < 25/HPF, 60 (9.4%) had microscopic hematuria with RBC ≥ 25/HPF and 70 (10.9%) had gross hematuria. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria (p <0.001). Symptomatic patients who had signs in the abdomen, back or inferior hemi-thorax mainly had microscopic hematuria with RBC < 25/HPF, but those with signs in the flank, mainly had microscopic hematuria with RBC ≥ 25/HPF (p<0.001). Pa- tients with pain, tenderness, abrasion, and ecchymosis in flank had a higher risk of positive UA findings (figure 2; p <0.001). Conclusion: Based on the findings of the present study, patients with any findings of pain, tender- ness, abrasion, or ecchymosis in flank had higher risk of abnormal UA and perhaps urogenital injuries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria. Keywords: Urinalysis; urogenital system; hematuria; multiple trauma; signs and symptoms Cite this article as: Zarmehri B, Shouman A, Pishbin E, Jafari Chokan N, Najaf Najafi M, Habibzadeh S R, Rayat Dost E, Foroughian M. Asso- ciation of Clinical Signs and Symptoms with Abnormal Urinalysis Findings of Blunt Trauma Patients; a Cross-Sectional Study. Arch Acad Emerg Med. 2019; 7(1): e64. 1. Introduction Trauma is the main cause of mortality in people aged 1-44 years (1). It accounts for more than 6 million deaths, yearly (2). Trauma related injuries are the main cause of long- lasting morbidity and disability, especially in young patients with their productive years ahead (3, 4). Although in the last ∗Corresponding Author: Mahdi Foroughian; Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mash- had, Iran. Tel: 05138525312, Email: foroughianmh@mums.ac.ir five decades management of trauma patients has advanced, trauma remains a serious health problem in all societies with different economic, social and health conditions (5). According to previous studies, abdomen is the third most common site in the body that requires surgical intervention following trauma. Nevertheless, the evaluation and diagnosis of intra-abdominal injury is still a challenge for doctors deal- ing with these patients (6). Most damage to abdominal or- gans is caused by abdominal blunt trauma (7, 8). Abdominal trauma could include genitourinary trauma, which includes a wide range of organs such as kidneys, ureters, bladder, ure- thra, penis, scrotum, and testicles (1). Kidneys are the most This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Zarmehri et al. 2 commonly affected organs in urinary trauma. They are in- jured in 5% of all traumas and in 10% of abdominal traumas (9). Renal and genitourinary trauma is seen in all age groups and in both sexes, although it is more common in men com- pared to women (10). Early identification and appropriate management of geni- tourinary tract damage can reduce potential long-term com- plications, including renal failure, chronic hypertension, uri- nary incontinence and sexual dysfunction (11). Signs, symp- toms and findings of clinical examinations in patients with genitourinary trauma are diverse and non-specific. These manifestations may include abdominal, rib, back, pelvic or testicular pain, urinary retention, penile and scrotal hematoma or ecchymosis and blood in the urethral meatus. In trauma patients, abdominal and pelvic computed tomog- raphy (CT) scan, with intravenous contrast, is the gold stan- dard for detecting kidney injury. However, to prevent the complications of this diagnostic method, urinalysis (UA) is performed as a screening test to determine the cases requir- ing CT scan (10). The negative results of urine tests in most of the cases, suggest that routine performance of this test must be reconsidered. Therefore, this study aimed to evaluate the relationship between clinical symptoms and UA findings of multiple trauma patients. 2. Methods 2.1. Study design and setting This cross-sectional study was carried out on multiple trauma patients, who were referred to the Emergency De- partment of Hashemi Nejad Hospital, Mashhad, Iran, be- tween September 2017 and September 2018. UA was per- formed for all patients and the association of UA with clin- ical signs and symptoms was evaluated. In the beginning of the project, the aim of the study was explained to the patients and after completing the informed consent form, patients were included. This research was approved by the Committee on Organizational Ethics of the Faculty of Medical Sciences, Mashhad University of Medical Sciences (IR.MUMS.fm.REC.1396.64). 2.2. Participants Patients less than 18 years of age, those with previous renal disease (such as stones, cysts, tumors, chronic kidney dis- ease, single kidneys), unstable hemodynamic, urinary tract infection, clear symptoms of duct injury (such as hematoma in perineum and blood at the meatus of the penis), and un- reliable examination (e.g. loss of consciousness, poisoning), those who were pregnant or on their menstrual period, and patients with penetrating trauma were excluded. 2.3. Data gathering On admission to the emergency department a complete his- tory was obtained and registered for each patient includ- ing demographic features such as gender and age, loca- tion of trauma (abdomen, flank, back, inferior hemi-thorax, and other locations), trauma mechanism (e.g. falling, ve- hicle crash, motorcycle, pedestrian crash, direct abdomi- nal trauma, direct back trauma, direct inferior hemi-thorax trauma, sudden impact injury), signs and symptoms (includ- ing pain, tenderness, abrasion, ecchymosis and hematoma in the abdomen, back, flank and inferior hemi-thorax), and associated injuries (inferior rib fracture, thoracolumbar ver- tebral fracture, pelvic fracture, long bone fracture, Intra- abdominal bleeding). Information about each patient was recorded using appropriate codes. UA was requested within 24 hours after trauma. Urine test results were divided into 4 separate categories including neg- ative UA, gross hematuria, microscopic hematuria with RBC (Red Blood Cells) <25/HPF and microscopic hematuria with RBC ≥ 25/HPF. All of these data were collected and put in a checklist. The urine test was interpreted by a blinded labora- tory technician. A trained emergency medicine resident was responsible for data gathering. 2.4. Statistical Analysis Data were analyzed via SPSS version 16 software. De- mographic data were presented using descriptive statistical methods, including central indicators, distribution and fre- quency distribution, in the form of appropriate tables and charts. ANOVA test was used to compare quantitative vari- ables between the four groups (based on the results of UA). Chi-Square test was used to compare qualitative variables between the four groups. In all calculations, p-value of 0.05 was considered as the level of significance. 3. Results 3.1. Baseline characteristics of studied patients A total of 640 patients with the mean age of 39.8 ± 11.2 years were studied (65.0% males). Table 1 summarizes the baseline characteristics of studied patients. The most frequent mech- anisms of trauma were pedestrian-vehicle accident (39.8%), motorcycle accident (34.4%), and falling (19.2%). 271 (42.4%) cases had associated injuries and 554 (86.6%) cases had at least one sign or symptom of trauma in abdomen, back, flank or inferior hemi-thorax. Distribution of clinical findings in mentioned locations are presented in table 2. 3.2. UA and clinical symptoms 146 (22.8%) patients had negative UA. Among cases with positive UA, 364 (56.9%) cases had microscopic hematuria This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2019; 7 (1): e64 Table 1: Baseline characteristics of studied patients Variables Number (%) Gender Male 416 (65.0) Female 224 (35.0) Trauma mechanism Falling down 123 (19.2) Motorcycle accident 220 (34.4) Pedestrian-vehicle accident 255 (39.8) Direct abdominal trauma 17 (2.7) Direct trauma (flank, back,. . . ) 25 (3.9) Associated injuries1 Inferior rib fracture 9 (3.3) Thoracolumbar vertebral fractures 41 (15.1) Pelvic fractures 36 (13.2) Long bone fractures 199 (73.4) Intra-abdominal hemorrhage 19 (1.1) Clinical signs and symptoms2 Pain 502 (90.6) Tenderness 399 (72.2) Abrasion 169 (30.5) Ecchymosis 96 (17.1) Hematoma 26 (4.6) 1: Some patients had more than one associated damage. 2: findings of abdomen, back, flank, and inferior hemithorax examination. with RBC < 25/HPF, 60 (9.4%) had microscopic hematuria with RBC ≥ 25/HPF and 70 (10.9%) had gross hematuria. There was not any significant relationship between age (p = 0.83), gender (p = 0.83), mechanisms of trauma (p = 0.29), or presence of associated injuries (p = 0.456) and UA find- ings. Figure 1 and table 3 show the distribution of UA find- ings based on presence or absence of symptoms. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria (p <0.001). Symptomatic pa- tients who had signs in the abdomen, back or inferior hemi- thorax mainly had microscopic hematuria with RBC < 25, but those with signs in the flank, mainly had microscopic hema- turia with RBC ≥ 25/HPF (p<0.001). Patients with pain, ten- derness, abrasion, and ecchymosis in flank had a higher risk of abnormal UA (figure 2; p <0.001). 4. Discussion Based on the findings of the present study, patients with any findings of pain, tenderness, abrasion, or ecchymosis in flank had a higher risk of abnormal UA and perhaps urogenital in- juries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria. In most centers, including ours, UA is used as a screening test to diag- nose intra-abdominal injuries, including renal injury. How- ever, the high number of normal results of this para-clinical method suggests that we need to create reliable clinical de- cision rules that could identify low-risk patients who do not require para-clinical examination. The most common mech- anism of trauma in the present study was pedestrian accident (39.8%). 50% of patients with direct flank trauma had mi- croscopic hematuria with RBC ≥ 25/HPF. This indicates the importance of this mechanism in predicting renal injury and the need for UA in this case, although there was no statisti- cally significant correlation between injury mechanism and UA results. Results of UA showed that most symptomatic patients have microscopic hematuria with RBC <25/HPF, or have nega- tive UA results. In addition, none of the asymptomatic pa- tients had gross hematuria or microscopic hematuria with RBC≥25/HPF. This suggests that if the patient does not have clinical symptoms, UA may be discarded. Moreover, 36.2% of patients with clinical symptoms in the flank area had micro- scopic hematuria with RBC ≥ 25/HPF. 37.3% of the patients with flank pain, 48.4% of patients with flank tenderness, 44% of patients with flank abrasion, 54.5% of patients with flank ecchymosis, and 30% of patients with flank hematoma, had microscopic hematuria with RBC ≥ 25/HPF. The rate of mi- croscopic hematuria with RBC ≥ 25/HPF was lower in other areas. This indicates the importance of these symptoms in the flank area. It should be noted that presence of ecchymo- sis and hematoma did not significantly correlate with UA re- sults, which is probably due to the small number of patients with these symptoms in the study. In categorizing patients into two groups of high risk for renal injury (microscopic hematuria with RBC ≥ 25/HPF or gross hematuria) and low risk for renal injury (negative UA or microscopic hematuria with RBC <25/HPF), the frequency of flank symptoms includ- ing tenderness, abrasion, and ecchymosis was significantly higher in those with a high risk of renal injury. This also signi- fies the importance of symptoms in the flank area. It can be concluded that the symptoms in the flank area are very im- portant, and if there are symptoms in this area para-clinical examination, including UA, is necessary to detect or rule out renal injury. Holmes et al. (2009) reviewed the rules that predict the risk of intra-abdominal injury to be low in patients with blunt abdominal trauma. The results showed that the use of a combination of Glasgow Coma Scale (GCS) less than 14, rib tenderness, abdominal tenderness, femoral fractures, hema- turia with RBC more than 25/HPF, hematocrit less than 30%, and abnormal chest radiography had 8.95% sensitivity, 29.9% specificity and 6.98% negative predictive value in the deter- mination of intra-abdominal injury. While, some of the crite- ria reviewed in this study differ from the criteria of our study, the results of the two studies are similar. Patients without the symptoms mentioned in the study had a lower risk of intra- abdominal injury (especially injuries requiring surgical inter- vention) and it seemed that patients would not benefit from This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Zarmehri et al. 4 Table 2: Distribution of clinical signs and symptoms according to their location Location Pain Tenderness Abrasion Ecchymosis Hematoma Abdomen 205 (40.8) 174 (43.6) 78 (46.2) 53 (55.2) 13 (50) Back 199 (39.6) 150 (37.6) 59 (34.9) 25 (26) 2 (7.7) Flank 83 (16.5) 62 (15.5) 25 (14.8) 11 (11.5) 10 (38.5) Hemi-thorax 15 (3) 13 (3.3) 7 (4.1) 7 (7.3) 1 (3.8) * Some patients had more than one clinical symptom. Data are presented as frequency (%). Table 3: Distribution of patients in terms of clinical symptoms, site of injury and urinalysis location Urinalysis P Negative RBC < 25 RBC ≥ 25 Gross hematuria Symptomatic patients Abdomen 52(24.6) 125(59.2) 10 (4.7) 24(11.4) Back 33(14.2) 150(64.4) 16(6.8) 34(14.6) 0.001 Flank 20(21.3) 30(31.9) 34(36.2) 10(10.6) Hemi-thorax 3(18.8) 11(68.8) 0 2(12.4) Pain Abdomen 49(23.9) 124(60.5) 10(4.9) 22(10.7) Back 28(14.1) 128(64.3) 15(7.5) 28(14.1) 0.001 Flank 19(2.9) 3(27.8) 31(37.3) 10(12) Hemi-thorax 3(20) 10(66.7) 0 2(3.3) Tenderness Abdomen 44(25.3) 100(57.5) 10(5.7) 20(11.5) Back 20(13.3) 99(66) 13(8.7) 18(12) 0.001 Flank 8(12.9) 18(29) 30(48.4) 6(9.7) Hemi-thorax 1(7.7) 10(76.9) 0 2(15.4) Abrasion Abdomen 23(29.5) 37(47.4) 6(7.7) 12(15.4) Back 12(20.03) 28(47.5) 12(20.03) 7(11.09) NA Flank 5(20) 5(20) 11(44) 4(16) Hemi-thorax 2(28.6) 4(57.1) 0 1(14.3) Ecchymosis abdomen 12(22.6) 30(56.6) 6(11.3) 5(9.4) Back 5(20) 12(48) 6(20) 3(12) NA Flank 2(18.2) 2(18.2) 6(54.5) 1(9.1) Hemi-thorax 2(28.6) 4(57.1) 0 1(14.3) Hematoma Abdomen 4(30.8) 6(46.2) 2(15.4) 1(17.6) Back 0 2(100) 0 0 NA Flank 2(20) 2(20) 3(30) 3(30) Hemi-thorax 0 1(100) 0 0 Data are presented based on frequency (%). RBC: red blood cell count per High Power Field. CT scan. Note that, in this study, intra-abdominal injury was studied in general, while in our study only the predictors of renal injury were considered (12). Jones et al. also reviewed the value of UA in blunt trauma pa- tients in 2017. UA was normal in 810 patients (45%). Among these 810 patients, 2 (0.2%) had genitourinary injury, but none of them required intervention. The researchers con- cluded that negative UA plays an important role in predicting or ruling out urogenital and intra-abdominal injuries. This helps in preventing exposure to unnecessary radiation. In this study, clinical manifestations had not been studied and the relationship of UA results with urogenital injury was ex- amined, but in general, it is consistent with the results of our study (13). In 2016 Sabzghabaei et al examined 325 patients with abdominal blunt trauma. In this study, urine test results were normal in about half of patients. The results of CT scan of 193 patients (59.6%) were normal overall and 90% were normal for kidney injury, where 32 (10%) had kidney injury. The researchers stated that UA has a low diagnostic value in predicting intra-abdominal injury in trauma patients, and it could be used as a helpful diagnostic tool, along with other sources, such as clinical findings and imaging. Unlike our study, this study did not address the clinical symptoms, but its conclusion was confirmed by our findings as it recom- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2019; 7 (1): e64 Figure 1: Distribution of urinalysis findings based on presence or absence of symptoms (pain, tenderness, abrasion, hematoma, etc.) in abdomen, back, flank or inferior hemi-thorax. RBC: red blood cell count per High Power Field. Figure 2: Association of clinical signs and symptoms with the risk of abnormal urinalysis findings (p < 0.001). mended the use of clinical findings as a diagnostic tool (14). In the same context, Mustafa et al. (2017) studied the value of UA in patients with abdominal blunt trauma. Out of the 100 patients who participated in the study, 56 had microscopic hematuria, 17 of which had gross hematuria, and 44 had no hematuria. Most patients who had intra-abdominal injury had hypovolemic shock (OR: 8.4, CI95%: 2.7-26), abdomi- nal wall hematoma (OR: 3.1, CI95%: 1.2-7.9), and/or anemia This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem B. Zarmehri et al. 6 (OR: 3.6; CI95%: 1.2-10.3), at the time, UA was not successful in predicting intra-abdominal injury. The researchers con- cluded that the use of UA is not effective enough to predict intra-abdominal injury, and should therefore not be used as a key component in patients with blunt abdominal trauma. Al- though the clinical criteria of this study differ from our study, the results of both studies are similar and indicate the im- portance of clinical symptoms in comparison to UA (15). In 2015, Olthof et al. conducted a retrospective study, to exam- ine the validity of UA in predicting traumatic urogenital in- jury. The incidence of intra-abdominal injury and urogen- ital injury were 13% and 8%, respectively. In this study, re- gardless of imaging findings, gross hematuria was detected in 73% of cases with urogenital injury, whereas microscopic hematuria was detected in only 4% of those patients. Olthof’s study, like our study, proves that UA is not an appropriate tool for predicting intra-abdominal injury. Therefore, the re- searchers suggested that UA should be removed from rou- tine trials in patients with blunt trauma and should only be used in specific cases. Note that, in contrast to our study, which was intended only for renal injury, this study exam- ined general intra-abdominal injuries (16). Not only studies on UA have shown the importance of clinical symptoms to decide on further para-clinical examinations and the need of screening tools, other studies investigating intra-thoracic damage have also shown the importance of clinical symp- toms in determining the need for further para-clinical stud- ies, which confirms our results. In most centers, including our center, routine UA is requested for all multiple trauma patients. This study demonstrates the importance of clinical symptoms for determining the need for para-clinical interventions and suggests the use of clini- cal signs to predict renal injury, which in turn prevents the imposition of additional costs and emergency crowding. 5. Limitation One of the limitations of this study was the lack of CT scans of participating patients due to its high costs and compli- cations. In addition, this study only covers patients who were referred to the Emergency Department of Hashemi Ne- jad Hospital. Since genitourinary trauma is associated with intra-abdominal trauma in many cases, and since hematuria is one of the symptoms of intra-abdominal injury, it would have been better to exclude patients with intra-abdominal injury. On the other hand, the focus on kidney injury and clinical symptoms is one of the strengths of this study. In or- der to increase the validity of the results, we suggest that for future studies, in addition to the registration of symptoms and clinical signs and hematuria, the study must be multi- centered and include CT scans of patients. 6. Conclusion Based on the findings of the present study, patients with any findings of pain, tenderness, abrasion, or ecchymosis in flank had a higher risk of abnormal UA and perhaps urogenital in- juries. None of the asymptomatic patients had microscopic hematuria with RBC ≥ 25/HPF and gross hematuria. 7. Appendix 7.1. Acknowledgements This study was the result of a doctoral research thesis con- ducted by Dr. Ayeh Shouman, which was sponsored by re- search deputy of Mashhad University of Medical Sciences under grant code 951246. We would also like to thank the Clinical Research and Development Unit of Peymanieh Edu- cational, Research and Therapeutic Center of Jahrom Univer- sity of Medical Sciences for revising the Manuscript. 7.2. Author contribution All the authors met the criteria of authorship based on the recommendations of the international committee of medical journal editors. Authors ORCIDs Bahram Zarmehri: 0000-0002-8687-1821 Elham Pishbin: 0000-0002-3082-8074 Niaz-Mohammad Jafari Chokan: 0000-0003-1872-574X Mona Najaf Najafi: 0000-0003-4962-6787 Seyed Reza Habibzadeh: 0000-0003-4569-1776 Esmaeil Rayat Dost: 0000-0002-9430-7913 Mahdi Foroughian: 0000-0002-3944-9361 7.3. Funding/Support This study was sponsored by research deputy of Mashhad University of Medical Sciences under grant code 951246. 7.4. Conflict of interest There are no conflicts of interest regarding this study. References 1. Walls R, Hockberger R, Gausche-Hill M. Rosen’s Emer- gency Medicine-Concepts and Clinical Practice E-Book: Elsevier Health Sciences; 2017. 2. Curry N, Davis P. What’s new in resuscitation strate- gies for the patient with multiple trauma? Injury. 2012;43(7):1021-8. 3. Organization WH. Violence, injuries and disability: bien- nial report 2008-2009. 2010. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 7 Archives of Academic Emergency Medicine. 2019; 7 (1): e64 4. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. The lancet. 1997;349(9063):1436-42. 5. Rice DP. Cost of injury in the United States: a report to Congress, 1989: Institute for Health & Aging, University of California, San Francisco; 1989. 6. Tan W, Chen C, Chiang H. The value and role of com- puted tomography in blunt injury of the abdomen. Zhonghua yi xue za zhi= Chinese medical journal; Free China ed. 1991;48(2):116-20. 7. McAninch JW. Genitourinary trauma. Urologic Clinics. 2006;33(1):xiii. 8. Poletti PA, Mirvis SE, Shanmuganathan K, Takada T, Killeen KL, Perlmutter D, et al. Blunt abdominal trauma patients: can organ injury be excluded without perform- ing computed tomography? Journal of Trauma and Acute Care Surgery. 2004;57(5):1072-81. 9. Bregstein JS, Lubell TR, Ruscica AM, Roskind CG. Nuk- ing the radiation: minimizing radiation exposure in the evaluation of pediatric blunt trauma. Current opinion in pediatrics. 2014;26(3):272-8. 10. Santucci R, Wessells H, Bartsch G, Descotes J, Heyns C, McAninch J, et al. Evaluation and management of renal injuries: consensus statement of the renal trauma sub- committee. BJU international. 2004;93(7):937-54. 11. Wright JL, Nathens AB, Rivara FP, Wessells H. Renal and extrarenal predictors of nephrectomy from the national trauma data bank. The Journal of urology. 2006;175(3):970-5. 12. Holmes JF, Wisner DH, McGahan JP, Mower WR, Kupper- mann N. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Annals of emergency medicine. 2009;54(4):575- 84. 13. Jones TS, Stovall RT, Jones EL, Knepper B, Pieracci FM, Fox CJ, et al. A negative urinalysis is associated with a low likelihood of intra-abdominal injury after blunt abdominal trauma. The American Journal of Surgery. 2017;213(1):69-72. 14. Sabzghabaei A, Shojaee M, Safari S, Hatamabadi HR, Shirvani R. The accuracy of urinalysis in predicting intra- abdominal injury following blunt traumas. Emergency. 2016;4(1):11. 15. Moustafa F, Loze C, Pereira B, Vaz M, Caumon L, Perrier C, et al. Assessment of urinary dipstick in patients admit- ted to an ED for blunt abdominal trauma. The American journal of emergency medicine. 2017;35(4):628-31. 16. Olthof DC, Joosse P, van der Vlies CH, de Reijke TM, Goslings JC. Routine urinalysis in patients with a blunt abdominal trauma mechanism is not valuable to detect urogenital injury. Emerg Med J. 2015;32(2):119-23. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Appendix References