Trainee Advanced Clinical Practitioner Diary- Day 14 - Critical Care Practitioner

Trainee Advanced Clinical Practitioner Diary- Day 14

Renal colic

kidney stones

Kidney stones are salts that form in the urinary tract. Commonly formed from calcium. There can be non calcium stones, from uric acid which is a by product of animal protein or systine which is an hereditary stone condition.

Affects 1-3% of adult population. Affects more males however some evidence now that it is affecting more women than before (Changing Gender Prevalence of Stone Disease. J Urol. 2007), possible related to diet and lifestyle.

Obese male has a 33% greater risk compared to non-obese male and obese female has a 90% greater risk compared to non-obese female! (Obesity, Weight Gain, and the Risk of Kidney Stones. JAMA 2005.) Patients who are obese tend to be relatively dehydrated when related to their body mass, they have acidic urine and because they are at risk of pre diabetes this will also cause them to have acidic urine.

Risk Factors

  • Family history of stone disease.
  • Intestinal disease/surgery
  • Gout- elevated uric acid.
  • Anatomic abnormalities/urinary diversion
  • Medications

Signs and symptoms

  • PAIN! Typically located in the flank or side. Can move to the front of the abdomen and be in the groin or genitals.
  • The pain may well move as the kidney stones progresses down the urinary tract.
  • Pain is episodic and movement does not make it worse.
  • It can be associated with nausea and vomiting.
  • There may be micro or macro heamaturia.
  • Not all stones cause pain.

Investigations

  • CT scan- CTKUB- need to be aware of risk of continued exposure to radiation with repeated scans.

Treatment

  • Pain killers and wait for the stone to be passed. Morphine/diclofenac.
  • Prevention- DRINK MORE! 3 litres per day if possible. Lemonade good to prevent kidney stones.(Urinary Volume, Water and Recurrences in Idiopathic Calcium Nephrolithiasis: A 5-year Randomized Prospective Study. J Urol. 1996).
  • Moderate calcium intake. Low calcium increases risks of stones. Limit dietary sodium and animal protein.
  • Moderate intake of tea, chocolate, nuts and spinach.
  • Extracorporeal shock wave lithotripsy (ESWL). ESWL is the most common way of treating kidney stones that cannot be passed in the urine. It involves using X-rays (high-energy radiation) or ultrasound (high-frequency sound waves) to pinpoint where a kidney stone is. A machine then sends shock waves of energy to the stone to break it into smaller pieces so it can be passed in the urine.
  • UreterorenoscopyIf a kidney stone is stuck in the ureter a ureterorenoscopymaybe the necessary procedure.  Ureterorenoscopy is also sometimes known as retrograde intrarenal surgery (RIRS).It involves passing a long, thin telescope called a ureteroscope through the urethra and into the bladder. It is then passed up into the ureter to where the stone is stuck.The surgeon may either try to gently remove the stone using another instrument, or they may use laser energy to break the stone up into small pieces so that it can be passed naturally in the urine.
  • Percutaneous nephrolithotomy (PCNL) (sorry for the cheesy music on this one!)PCNL is an alternative procedure that may be used for larger stones. It may also be used if ESWL is not suitable (for example, because the person being treated is obese)

The San Francisco Syncope Rule (SFSR) is a simple rule for evaluating the risk of adverse outcomes in patient who present with fainting or syncope.

The mnemonic for features of the rule is CHESS:

C – History of congestive heart failure

Hheamatocrit < 30%

E – Abnormal ECG

S – Shortness of breath

S – Triage systolic BP < 90

A patient with any of the above measures is considered at high risk for a serious outcome such as death, myocardial infarction, arrhythmia, pulmonary embolism,stroke, subarachnoid hemorrhage, significant heamorrhage, or any condition causing a return Emergency Department visit and hospitalization for a related event. If they meet the above criteria then:

  • 10.0% will have a 7-day serious outcome
  • 0.4% will die by 7 days
  • Importantly 1.4% of patients that are San Francisco Syncope Rule-negative will have a 7-day serious outcome

San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review. CMAJ 2011

Accuracy and quality of clinical decision rules for syncope in the emergency department: a systematic review and meta-analysis. Ann Emerg Medicine 2010.

Failure to validate the San Francisco Syncope Rule in an independent emergency department population. Annals of Emergency Medicine 2008

Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis. Annals of Emergency Medicine 2010 – I plan to do a proper full review of this paper as it seems to have a lot of valuable points.

Physical examination findings include the following:

  • Rebound tenderness, pain on percussion, rigidity, and guarding: Most specific finding
  • RLQ tenderness: Present in 96% of patients, but nonspecific
  • Left lower quadrant (LLQ) tenderness: May be the major manifestation in patients with situs inversus or in patients with a lengthy appendix that extends into the LLQ
  • Male infants and children occasionally present with an inflamed hemiscrotum
  • In pregnant women, RLQ pain and tenderness dominate in the first trimester, but in the latter half of pregnancy, right upper quadrant (RUQ) or right flank pain may occur

The following accessory signs may be present in a minority of patients:

  • Rovsing sign (RLQ pain with palpation of the LLQ): Suggests peritoneal irritation

  • Obturator sign (RLQ pain with internal and external rotation of the flexed right hip): Suggests the inflamed appendix is located deep in the right hemipelvis

  • Psoas sign (RLQ pain with extension of the right hip or with flexion of the right hip against resistance): Suggests that an inflamed appendix is located along the course of the right psoas muscle

  • Dunphy sign (sharp pain in the RLQ elicited by a voluntary cough): Suggests localized peritonitis
  • RLQ pain in response to percussion of a remote quadrant of the abdomen or to firm percussion of the patient’s heel: Suggests peritoneal inflammation
  • Markle sign (pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing)

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