GU/renal Flashcards
pathophys of rhabdo
from destruction of skeletal muscle due to injury of myocytes
common causes of rhabdo
drugs of abuse (cocaine, meth), alcohol (direct toxic effect and coma induced muscle breakdown aka passing otu no muscle), medications (antipsychotics, statins, SSRI, huge list), muscle diseases, trauma, NMS, seizures, immobility, infection, strenous physical activity, heat-illness.
** more than 1/2 the time there are multiple causes present
rhabdo symptoms
weakness, myalgias, malaise, dark brown urine (tea colored urine)
if severe can lead to n/v, abdo pain or even urea induced encephalopathy
rhabdo cutoffs for dx, IVF and trend, vs admit
> 1000 is dx
5000 probable admit
dialysis indications in rhabdo?
same as any other pt… AEIOU
treatment of rhabdo
aggressive IV fluid (Ns or RL), for 24 to 72 hours. target OU of 200 mL per hour or 3 mL/kg/hr.
basically, boluses then 250-500 mL per hour based on pt factors (age, EF etc)
4 general complications of rhabdo
AKI, DIC, electrolyte abn (K, P, Ca), mechanical complications (compartment syndrome, peripheral neuropathy)
uremic symptoms
n/v, drowsiness, fatigue, confusion, if untreated coma
fastest screening test for hyperK?
ECG
detects 50% of levels over 6.5
creatinine changes required for AKI
Cr increase of 26, over less then 48 hrs
ACE inhibitor effects on kindeys
decrease GFR, but also decrease glomerular pressure
preferentially vasodilate efferent arteriole
NSAIDs effect on kidney arterioles
vasoconstrict afferent
general treatment principles in AKI
target euvolemia, hold insulting meds, relieve/rule out obstruction (u/s and foley)
look for hyper K, metabolic acidosis (WAGMA), proteinuria etc.
indications for acute dialysis
A: refractory/life threatening acidosis
E: refractory hyper K (>6.5 and not improving)
I: life-threatening ingestion of dialyzable drug (common methanol/ethylene glycol, salicylates, lithium)
O: refractory overload (causing hypoxia)
U: symptomatic uremia (pericarditis, encephalopathy, bleeding)
hyperkalemic ECG
peaked T waves, prolonged PR, wide QRS and then sinusoidal pattern
broad definition of cardiorenal syndrome
acute or chronic dysfunction of one organ causes acute or chronic dysfunction of the other
metformin and contrast CT
if gfr >30 and on metformin go for it, otherwise hold metformin for 48 hrs before and after (if possible)
define uremia
a (poorly named) clinical syndrome, involves accumulation of urea AND OTHER metabolites in the blood which cause sequalae that are not solely resolved by dialyzing them out, it is the end-point of CKD/ESRD…. interestingly BUN is inaccurate marker of uremia severity
uremic neurologic complications (3):
uremic encephalopathy, dialysis dementia, peripheral neuropathy
cardiovascular complications of uremia
elevated troponins, HTN, HF, uremic cardiomyopathy, pulm edema, tamponade, pericarditis, CAD
unique feature of uremic pericarditis?
aseptic and inflammatory cells dont enter myocardium, so you dont get the ECG changes!
hematologic complications of uremia? 3
anemia, coagulopathy, immune disorders
do you remove dialysis line if infected?
generally trial IV abx for 2-3 days first.
what is Branham sign?
indicates high out put HF/AV fistula steal syndrome, you occlude fistula and look for drop in HR.
complications during dialysis (4)
hypotension (often due to volume loss), dialysis dysequilibrium (due to osmolar changes, s/s are n/v and HTN, can be life threatneing), air embolism, electrolyte abn
most common organisms in PD peritonitis?
staph and strep, gram neg can occur too
signs/symptoms of PD peritonitis
fever, abdo pain, guarding, peritonitic signs
size of catheter in acute urinary retention
14-16F
what is coude tip catherter?
has angled and firm tip, which should be angled anterioirly to follow the anatomy
Causes of acute urinary retention
normal bladder scan and PVR
scan should be less then 400 mL, PVR should be less than 150 mL
contraindications for urethral catheterization?
recent urological surgery
what is post obstructive diuresis? what to do about it?
after initial drainage of bladder, observe for 2-4 hours, looking for >200 cc/hr of output.
if this happens, consult medicine for admission and start volume replacement that is equal to their losses
TOV in urinary retention
should be done in 3 days, remove catheter, aggressive po rehydration, and measure PVR at 4-6 hours. should be less than 150-200 mL.
who is at risk for post obstructive diuresis?
long standing obstruction, poor renal function, HF, AMS and underlying comorbidity.
Management of urinary retention with clots or gross hematuria
Insertion 20-24 F triple lumen catheter and irrigate with saline until clots are cleared. If clots persist consult uro
Algo for urinary retention
definition of asymptomatic bacturia
2 clean catch cutlures in women
1 clean catch culture in men
without symptoms, only treat if pregnant or about to have invasive GU procedure
which UTI bugs dont produce nitrites?
pseudomonas, enterococcus,
Abx for pregnant cystitis
Macrobid, cefixime, keflex
Ddx for dysuria
pathophys of fournier’s gangrene, RF for it?
starts as benign infection or simple abcess, then turns into necrotizing infection, can occur in women too (20% of cases).
RF: DM, immuno comp etc
abx for fourniers?
pip-taz, vanco + surgical debridement
balanoposthitis:
what is it?
s/s
tx
inflammation of glans and foreskin
treatment: antifungals or abx or steroid cream
phimosis
what is it?
s/s
tx
cannot retract foreskin
normal until adolsecne, but only 10% remain unretractable by age 3
tx is steroid cream or circumcision
paraphimosis
what is it?
s/s
tx
fore skin stuck retracted (true emergency)
-can lead to ischemia of glans
-tx: reduction – >apply EMLA –> wrap glans for 5 mins with plastic (?coban)–> manual reduction with fingers/thumbs –> doesn’t work dorsal block and make a slit.
penile fracture
what is it?
s/s
tx
what breaks in penile fracture?
tunica albuginea
2 main causes of priapism
sickle cell, medications
ischemic vs non ischemic priapism
ischemic –> veno occlusive, low flow
non ischemic –> arterial, high flow –> PAINLESS
can use blood gas from penis or Doppler to help differentiate too
treatment of priapism
corporal aspiration, irrigation and injection with phenylephrine
torsion ddx
torsion, appendigeal torsion, epididymitis, orchitis, hernia, trauma
time frame to target detorsion
<6 hrs = excellent results
most sensitive finding in to r/o torsion?
cremasteric reflex present bilat = 75-96% sens
exam findings in torsion
swollen, firm, high-riding, transverse lie, absent cremasteric reflex.
how to manually detort?
2/3 of bases –> opening a book,
1/3 of cases = opposite of that, if pain worsens with book opening try the other way
blue dot sign is pathognomonic for?
appendageal torsion
treatment of epididymitis by organisms and age
> 35 treat for e coli and klebiella = levo or cipro
< 35 treat for G+C = ctx and doxy
%age of normal u/a in epididymitis?
50%
symptoms of prostatitis
LUTS, back pain, pelvic pain, fever, chills, dyschezia, painful ejaculation
most common organisms for prostatitis? empiric tx for prostatitis?
e colie, then other uropathogens
fluoroquinolone for 2 weeks
Does decreasing calcium diet help with stones?
No, does opposite. Causes more calcium release from bones
Composition of kidney stones
80%: calcium phosphate or oxalste
10%: struvite
10%: Utica acid
3 common stone locations
UPJ
Pelvic brim
UVJ
What %age of pts with renal colic have hematuria?
85%
Most common miss with renal colic
AAA.. remember that it is rare for first time presentation of renal colic in pt > 60
Ddx if renal colic
%age of passage based on stone size
<5 mm, 98% at 4 week
5-7 60% at 4 weeks
Should talked to uro about stones >5 and defs >7
mgmt of UTI and kidney stones
if obstruction, AKI, fever, other systemic signs = admission, IV ABX and uro consult for septic stone
if UTI and stone, but no other symptoms = oral abx and r/a in 48-72 hrs
% age of kidney stones seen on xray
85% b/c the calcium ones have same density as bone roughly.
general sensitivities and specificity of CT, US and xray for kidney stones
medical expulsion therapy in stones
Tamsulosin is recommended, most impact in stones > 5 mm
reasons for admission with kidney stone?
refractory pain/vomiting, septic stone, single kidney/renal transplant, severe comorbidity, hypercalcemic crisis
avergae time to stone passage
varies, on size and location ,but 7-30 days (lol)
