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Conference December 2020 (Renal/GU)

Happy Holidays to you and yours!

We have taken a small break here on the academic side for a couple of weeks, the next set of interviews and proceedings start back up mid January. In the mean time hopefully you enjoy the holiday proceedings as much as can be, in this very unusual year. For this article I think we will make it brief so we can round out the year.

From left to right: Dr Iloma (PGY2), Dr Crist (PGY2), Dr Bulga (PGY1), Dr Barbaro (PGY1), Dr Howard (PGY1)

Onto business

Lets talk nephrolithiasis briefly – You have a patient with suspected kidney stone. here are some pearls regarding urolithiasis and management:

  • CT scanning for nephrolithiasis from the ED utilization has increased x 10 fold over the past decade or so.
  • If the patient has no prior hx of stones CT may be reasonable. Consider CT w/contrast > CT non-con if other DDx suspected ie retroperitoneal pathology, pancreatitis, psoas abscess, AAA etc.
  • If prior hx of stones consider US in place of CT. If elevated sCr and +Hydronephrosis on US with suspected non-visualized ureteral stone then consider proceeding to CT vs consulting urology.
  • Obstructing stones w/significant hydronephrosis or elevated sCr, Horsehoe kidney, solitary kidney, renal transplant, infected stone, hx of recurrent prior instrumentation, urogenital development abnormalities, uncontrolled DM or immunocompromised always necessitates Urology consult/management. (1,2)


Dialysis complications

  • Uremia can cause nausea, AMS, vomiting, anorexia, FTT
  • Systemic calcification issues –> renal osteodystrophy due to loss of vit D, calcium-phosphate joint deposition, bone pain, pathological fractures
  • Anemia of chronic disease
  • peripheral uremic induced neuropathy vs vasculopathy/limb ischemia
  • Missed HD –> volume overload, accelerated HTN, hyperkalemia. NPPV is your friend here. Fix hyperK+. treat HTN crisis. Emergent/Urgent HD needed in most cases.
  • Altered VWF (von willebrand factor) with platelet dysfunction. Increased incidence of bleeding – also these patients get >50k U of Heparin during HD. All increase bleeding risks, especially ICH. Supplement DDAVP and cryoprecipitate. transfuse PRBC’s to Hct >30.
  • Dialysis disequilibrium syndrome –> AMS during or after HD with ataxia some cases, +headache +/- N/V. caused by fluid shifts during HD. Needs HCT to eval other causes of AMS/AMS workup. If severe needs mannitol or 3% Saline infusion.
  • Dialysis fistulas –> Persistent bleeding needs control with topical thrombotics ie Gelfoam etc, or suturing if severe. Consider protamine administration if pt arrived with bleeding fistula immediately after HD to address heparin use during HD. Always check Vascular US of the fistula to ensure no pseudoaneurysm formation. If present –> Vascular surgery/IR consult.
  • Infected grafts/catheters –> Common. Consider this as a source in suspected septic ESRD pts.
  • Peritonitis in PD patients –> aspiration of peritoneal fluid for culture/Dx. PD fluid with: >100 WBC/mm3 with >50% neutrophils or a positive Gram stain is positive. Tx –> intraperitoneal abx – Vanc + 3rd gen cephalosporin or directed per Cx. (3)

From left to right: Dr Bryant (Clinical faculty), Dr Tessitore (PGY3), Dr Carroll (PGY1), Dr Boone (PGY2)


GC/Chlamydia

  • The CDC recently updated the guideline for empiric tx of gonorrhea from 250mg IM ceftriaxone to 500mg x1. (4)
  • If chlamydial infection has not been excluded, Azithromycin 1000mg x1 or doxycycline 100 mg orally twice a day for 7 days is recommended.
  • When ceftriaxone cannot be used for treating urogenital or rectal gonorrhea because of cephalosporin allergy, a single 240 mg IM dose of gentamicin plus a single 2 g oral dose of azithromycin is an option.


Prostatitis

  • Urgency, dysuria, frequency, urinary retention. Tender swollen prostate that is firm and warm to the touch (avoid prostatic massage as it may precipitate bacteremia). Tx –> Age <35 years: Ceftriaxone (IM × 1) or ofloxacin (× 10 days) and doxycycline (× 10 days) . Age ≥35 years: Fluoroquinolone or Trimethoprim/sulfamethoxazole for 2–4 weeks. Chronic bacterial: fluoroquinolone × 4 weeks or trimethoprim/ sulfamethoxazole for 1–3 months. Avoid urethral catheterization, use suprapubic aspiration.


Epididimytis/orchitis

  • Prehn sign: relief with scrotal elevation
  • + cremasteric reflex intact
  • Consider US to evaluate other causes of testicular discomfort.
  • Tx: Prepubertal boys: Augmentin or trimethoprim/sulfamethoxazole. Men <35 years: Ceftriaxone and doxycycline . Men ≥35 years: same or consider fluoroquinolone as 3rd line.

From left to right: Dr Brewer (PGY3), Dr Scarborough (PGY3), Dr Abdel-Raziq (PGY3)


Nice and short! enjoy your holidays. See you at the next conference!

References

  1. Herbst M, Rosenberg G, Daniels B et al. Effect of Provider Experience on Clinician-Performed Ultrasonography for Hydronephrosis in Patients With Suspected Renal Colic. Annals of emergency medicine. 2014;64(3):269-76. doi:10.1016/j.annemergmed.2014.01.012.
  2. Carnell J, Fischer J, Nagdev A. Ultrasound detection of obstructive pyelonephritis due to urolithiasis in the ED. The American Journal of Emergency Medicine. 2011;29(7):843.e1-843.e3. doi:10.1016/j.ajem.2010.07.006.
  3. Baun K, Easter J. Marx: Rosen’s Emergency Medicine-Concepts And Clinical Practice. 8th ed. Elsevier Health Sciences; 2013:1336-1342.
  4. Weekly / December 18, 2020 / 69(50);1911–1916. Sancta St. Cyr, MD1; Lindley Barbee, MD1,2; Kimberly A. Workowski, MD1,3; Laura H. Bachmann, MD1; Cau Pham, PhD1; Karen Schlanger, PhD1; Elizabeth Torrone, PhD1; Hillard Weinstock, MD1; Ellen N. Kersh, PhD1; Phoebe Thorpe, MD


Image credits
S. Meyering DO FAAEM FACEP
Unsplash/Xmas

Stefan Meyering DO, FAAEM, FACEP

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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