MDT's Part 3 Flashcards
What is testicular torsion?
Testi torse (twist) on the spermatic cord, potentially producing ischemia from reduced arterial inflow and venous flow obstruction
What does testicular torsion require?
Emergent diagnosis to salvage testicle
- treat within 6-8 hours to salvage testi
Who does testicular torsion usually affect and how?
- Young men, rare in men older than 30
- Usually rotates medially
What are some signs and symptoms of testicular torsion?
- Acute scrotal pain
- Profound tenderness and swelling
- Nausea/vomiting
- Negative cremasteric reflex
- Bell clapper deformity (high-riding testi oriented transversely)
Imaging for testicular torsion?
Scrotal U/S (with color flow doppler)
Treatment for testicular torsion?
- Manual detorsion
- Surgical detorsion
What is the etiology of penile trauma?
- Diverse mechanisms
- 25% injuries to external genitalia require RBC transfusion due to blood loss
What are some self-inflicted injuries associated with penile trauma?
- Amputation
- Vacuum injuries
- Zipper injuries
- Constriction/strangulation injuries
- Degloving injuries
- Penetrating injuries
- Contusions
Treatment of penile trauma?
- Conservative treatment
- Analgesics/NSAIDS
- Rest
- Ice packs
- Elevation
Imaging for penile trauma?
- Retrograde urethrogram
- Scrotal/penile U/S
Immediate urological consult for surgical intervention with penile trauma?
- Urethral injury
- Amputations
- Degloving
- Penetrating injuries
- Penile trauma
MEDEVAC
If there is penile trauma with associated urethral injury, what is contraindicated?
Foley Catheter
What is Phimosis?
Fibrous constriction of the foreskin preventing retraction
What can phimosis be a result of?
- Balanitis
- Balanoposthitis
What is Balanitis?
Inflammation of glans penis
What is balanoposthitis?
Inflammation of glans penis and prepuce
Can phimosis cause urinary retention and what can be done?
Yes
- Foley catheter for urinary retention unless it cannot be passed
- Suprapubic catheterization if Foley cannot be passed
What is the most common infectious cause of underlying balanoposthitis in phemosis?
Candidal infection
- Treat iwith good hygiene and topical antifungal
- Clotrimazole, Miconazole
What is Paraphimosis?
- True urologic emergency
- Occurs when retracted foreskin develops a fixed constriction proximal to glans
What are some manual reductions of paraphimosis?
- Compress glans firmly for 5-10 minutes
- tightly wrap glans with 2 inch bandage
- Ice
- Dorsal nerve block (must discuss with MO prior)
If manual reduction of paraphimosis does not work, what can be done?
- Dorsal slit of the foreskin
- Discuss with Physician Sup prior
- Incision of band will allow for foreskin retraction
- Referral to urology for elective circumcision
What is the result of Acute Kidney Injury?
- Sudden decrease in kidney function
- Inability to maintain acid-base, fluid, and electrolyte balance and to excrete nitrogenous waste
Acute Kidney Injury (AKI) can be divided into what 3 categories?
- Pre-renal
- Intrinsic Kidney disease
- Post renal
What is the first step in treating AKI?
Identifying the cause
General considerations for pre-renal AKI?
- Most common etiology
- If reversed quickly, renal blood flow damage to kidneys does not occur
- Hypoperfusion can lead to secondary intrinsic kidney injury
How does decreased renal perfusion occur?
- Decreased intravascular volume (blood loss, GI loss, dehydration)
- Change in vascular resistance (Sepsis, anaphylaxis)
- Low cardiac output (Cardiogenic shock, heart failure, PE)
General considerations for post-renal AKI?
- Least common cause
- Important to detect because it’s reversable
Causes of post-renal AKI?
- Urethral obstruction
- Bladder dysfunction/obstruction
- Obstruction of both ureters/pelvis
- Benign Prostatic hypertrophy
- Cancer
General considerations for intrinsic AKI?
- Up to 50% of cases
- Considered after rule out of pre and post renal
Sites of injury for intrinsic AKI?
- Tubules
- Interstitium
- Vasculature
- Glomeruli
Signs and symptoms of AKI?
- Non-specific signs (N/V, malaise, pericarditis)
- Pericardial effusion
- Arrythmias
- Rales in hypervolemia
- Abdominal pain
Lab findings for AKI?
- Blood urea nitrogen
- Creatinine
- Urinalysis
Imaging for AKI
Renal U/S
Treatment of pre-renal AKI?
- Depends on cause
- Achieve renal perfusion
- Avoiding nephrotoxic drugs
Treatment of post-renal AKI?
- Bladder catheterization
- Relieve underlying cause
Treatment of intrinsic AKI?
- Usually self-limited
- Managed by nephrology
Follow up and referral for AKI?
- Most patients will be MEDEVAC
- Pre-renal: Emergency medicine, Cardiology, Internal medicine
- Post-renal: Urology for obstruction
- Intrinsic: Nephrology
General considerations for Hyponatremia?
- Serum sodium levels <135 mEq/L
- Most common electrolyte abnormality
- Usually reflects excess water-retention relative to sodium
Evaluation for hyponatremia starts with?
- New medications
- Changes in fluid intake
- Fluid output
Mild symptoms of hyponatremia?
- Usually asymptomatic
- Nausea
- Malaise
Moderate symptoms of hyponatremia?
- HA
- Lethargy
- Disorientation
Severe symptoms of hyponatremia?
- Respiratory arrest
- Seizure
- Coma
- Permanent brain damage
- Brainstem herniation
- Death
Treatment of hyponatremia?
- Restriction of free water and hypotonic solution initial step
- Free water intake should be less than 1-1.5L/day
Hospitalization for hyponatremia?
- Severe and symptomatic hyponatremia for:
- monitoring fluid balances and weights
- treatment
- frequent sodium checks
General considerations for hypernatremia?
- Sodium concentration >145 mEq/L
- Typically hypovolemic
- Intact thirst mechanism and access to water are primary defense
Symptoms in a dehydrated hypernatremia patient?
- Orthostatic hypotension
- Oliguria (small amounts of urine)
Early signs of hypernatremia?
- Lethargy
- Irritability
- Weakness
Severe signs of hypernatremia?
- Na >158
- Hyperthermia
- Delirium
- Seizures
- Coma
Treatment of hypernatremia?
- Correcting cause of fluid loss
- Replacing water
- Replacing electrolytes as needed
- Fluids should be administered over a 48 hour period (serum Na correction of approx 1mEq/L/Hr)
Who requires hospitalization for hypernatremia?
Symptomatic hypernatremia
Natermia vs kalemia?
Sodium vs Potassium
General considerations for hypokalemia?
Serum potassium <3.5mEq/L
- Severe may induce arrythmias or rhabdo
What can hypokalemia result from?
- Insufficient dieetary potassium intake
- Intracellular shifting of potassium from extracellular space
- Blocked by alpha-adrenergic stimulation
What is the most common cause of hypokalemia?
GI loss from infectious diarrhea
* intestinal secretion is 10x higher than gastric secretion
Signs of mild to moderate hypokalemia?
- Muscular weakness
- Fatigue
- Muscle cramps
Signs of severe hypokalemia?
- <2.5mEq/L
- Flaccid paralysis
- Hyporeflexia
- Hypercapnia
- Tetany
- Rhabdomyolysis
Imaging for hypokalemia?
- ECG may show
- Decreased amplitude and broadening of T waves
- Premature ventricular contractions
- Depressed St segments
Treatment for hypokalemia?
Oral potassium supplementation is quickest and easiest
Follow up for hypokalemia?
Unexplained or refractory hypokalemia referred to Endocrinology or Nephrology
General considerations for hyperkalemia?
- Serum K level >5.0 mEq/L (repeat to rule out false hyperkalemia)
- ECG may be normal
- Usually occurs in Pts with advanced kidney disease
- Acidosis causes intracellular potassium to shift extracellularly
Hyperkalemia may develop in Pts taking?
- ACE inhibitors
- Angiotensin-receptor blockers
- Potassium sparing diuretics
Signs of hyperkalemia?
- Muscle weakness
- Flaccid paralysis
- Ileus
Imaging for hyperkalemia?
- ECG may reveal
- Bradycardia
- PR interval prolongation
- Peaked T waves
- QRS widening
Treatment of hyperkalemia?
- Withhold exogenous K
- Identify cause
- Review medication and dietary K intake
- Insulin, bicarbonate, and beta-agonist
- Loop diuretics
Emergent treament for hyperkalemia when?
- Cardiac toxicity
- Muscle paralysis
- Severe hyperkalemia ( K level >6.5)
Follow up for hyperkalemia?
Severe hyperkalemia sent to ED
