RENAL COLIC

Question 1

Approach to the Critically Ill Renal Colic

Answer 1

CIRCULATION:
Isotonic Crystalloid IV Bolus 20 cc / kg

Pediatrics:
10-20 ml/kg crystalloid bolus

Multimodal Analgesia:

Toradol 10 mg IM. Avoid in renal disease, PUD, history of gastrointestinal bleed.

Acetaminophen 1000 mg PO q 6 hr

Morphine 1-4 mg IV (0.05-.0.1 mg/kg) up to 10 mg q 4 hrs

Hydromorphone 0.2-0.5 mg IV up to 1 mg q 4 hrs

Ketamine 0.3 mg / kg slow IV push

Ondansetron 4 mg IV

Metaclopramide 10 mg slow IV Can administer with diphenhydramine 25-50 mg intravenous as prophylaxis against dystonia.

Haloperidol or droperidol 1.25-5 mg IV / IM for intractable nausea/vomiting, acute on chronic abdominal pain, gastroparesis, and cannabis hyperemesis syndrome

EXPOSURE:
POCUS to evaluate for hydronephrosis

Consider antibiotics for potential UTI

U/A
Renal Panel

Question 2

DDx

Answer 2

GU:
Pyelonephritis
Renal Infarct
Renal Neoplasm

GYN:
Ovarian Torsion
Testicular Torsion

GI:
Appendicitis
Biliary Colic
Intestinal Obstruction

Vascular:
Mesenteric Ischemia
AAA
Aortic Dissection

Question 3

Most Common Misdiagnosis

Answer 3

AAA
Patient > 50 with flank pain should be evaluated for AAA

Question 4

Types of Stone

Answer 4

Calcium Oxalate (MC, 75%)
Struvite (15%)
Uric Acid (10%)
Cystine (1%)

Question 5

Size and Progosis for stone passing

Answer 5

< 5mm - 90% Pass
5-8 mm - 15% Pass
> 8 mm - < 5% Pass

Question 6

Most Common Site for Obstruction

Answer 6

Ureterovesicular Junction

Question 7

History & Physical

Answer 7

Acute onset

Crescendo pain begins in flank exdending laterally
around the abdomen and radiating into the groin

Pain out of proportion

a/w
N/V
Gross Hematuria

PMHx: Gout, Nephrilithiasis
Family Hx
Diet (high oxalate or Na, low fluid)

Should ONLY be unilateral CVA tenderness

Always evaluate for pulsatile mass, abdominal bruit, diminished / absent pulses in distal extremities to r/o AAA

Question 8

Investigations

Answer 8

Cr
U/A + UClx 10-20% have no microscopic hematuria
Renal Panel
BHCG in females

CT abdomen non contrast helical (spiral) GOLD STANDARD

Ultrasound abdomen

XRAY

Question 9

Advantages and Limitations of CT

Answer 9

Most sensitive and specific

No contrast - can miss AAA, appendicitis, renal infarction or dissection

Question 10

U/S: Advantages and Limitations

Answer 10

Advantages:
High sensitivity and specificity for hydronephrosis
Pregnant and children - an alternative to assess hydronephrosis

Limitations:
36% - 64% sensitive
Difficult to pick up stones 5 mm or less

Question 11

Acute ED Management

Answer 11

Isotonic Crystalloid IV Bolus 20 cc / kg

Pediatrics:
10-20 ml/kg crystalloid bolus

Multimodal Analgesia:

Toradol 10 mg IM. Avoid in renal disease, PUD, history of gastrointestinal bleed.

Acetaminophen 1000 mg PO q 6 hr

Morphine 1-4 mg IV (0.05-.0.1 mg/kg) up to 10 mg q 4 hrs

Hydromorphone 0.2-0.5 mg IV up to 1 mg q 4 hrs

Ketamine 0.3 mg / kg slow IV push

Ondansetron 4 mg IV

Metaclopramide 10 mg slow IV Can administer with diphenhydramine 25-50 mg intravenous as prophylaxis against dystonia.

Tamsulosin 0.4 mg PO daily 7-10 days for stones < 5 mm

Question 12

Disposition Home

Answer 12

Tamsulosin 0.4 mg PO daily 7-10 days for stones < 5 mm

Follow up with urology or family physician

Question 13

Absolute Indications for Urologic Consult and Hospital Admission

Answer 13

Obstructing stone with signs of urinary tract infection
Intractable nausea / vomiting
Ongoing severe pain requiring parenteral analgesia
Urinary extravasation

Question 14

Relative Indications for Urologic Consult and Hospital Admission

Answer 14

Significant comorbid illness complicating outpatient management
High grade obstruction
Leukocytosis
Stone size > 8 mm
Solitary kidney / intrinsic renal disease
Psychosocial factors affecting home management