When to send the patient home? Medical Student Notes

Author: Hiro Miyagi OSU MS4 // Editor: Michael Barrie OSU EM Attending

Medical Student Corner – When do kidney stone patients need immediate intervention?

A 51yo female presents with an acute episode of severe right sided back pain with nausea and vomiting. Patient has a past medical history of HTN and chronic back pain. The pain is intermittent, described as sharp and stabbing 10/10 pain. She has not been able to tolerate any liquids since the onset of pain. The patient denies fevers or chills, with no recent infections or illnesses. No dysuria, but with mild urinary frequency. She has a past surgical history of appendectomy 30 years ago.

Vital signs: Afebrile, HR: 96, RR: 16, bp: 140/98, SPO2: 100% on room air.

On exam, the patient appears restless, abdomen is soft but tender on the RLQ. Heart and lung exams are unremarkable. There is no CVA tenderness.

Labs: Creatinine: 0.98, wbc: 11, Hgb: 13.4, UA shows trace blood, positive nitrites, negative leukocytes, many squamous epithelial cells.

CT scan: 3.5mm x 4mm obstructing R ureteral stone with mild right hydronephrosis

Patients with kidney stones are no strangers to emergency physicians. While the differential for flank pain can include renal or ureteral stones, pyelonephritis, lobar pneumonia, AAA, hydronephrosis, and gynecologic causes among many others, I wanted to specifically discuss flank pain secondary to kidney stones and what the indications are for prompt intervention.

During my emergency medicine rotation, I was taught that disposition is one of the most important questions to answer while in the ED. Can the patient go home? Do they need further studies? Do they need prompt intervention? Below I have reviewed the indications for prompt intervention in kidney stone patients.

Indications for prompt intervention

  1. Prolonged complete or high grade unilateral urinary obstruction.
  2. Any degree of bilateral urinary obstruction.
  3. Any degree of urinary obstruction in a solitary kidney.
  4. Any degree of urinary obstruction with urinary infection or sepsis.
  5. Any degree of urinary obstruction with a rising creatinine.
  6. Symptoms refractory to medical management – Inability to tolerate oral intake because of severe nausea or vomiting, or severe pain not controlled by oral analgesics.

Can this patient go home? This patient has positive nitrites suggesting that she has a UTI which is a definite indication for a stone intervention. But wait– upon closer inspection, we can see that her UA is contaminated with many squamous epithelial cells. A repeat UA was ordered (consider straight catheterization if repeat UA is contaminated). On repeat testing nitrites were negative. In an otherwise healthy female with a 4mm ureteral stone, she has a greater than 60% chance of passing the stone with time. Patients should be prescribed pain medications – NSAIDs, Tylenol, and consider opiates. Consider alpha-antagonists such as tamulosin especially when kidney stones are larger than 6mm. And like nearly all ED patients we send home, recommend aggressive fluid hydration.

The next time you see a kidney stone patient, I hope that review of these indications can help you determine the disposition of the patient.

Case Conclusion

After Toradol 15mg IV and oral Tylenol, the patient’s pain is controlled and she is now able to drink some water. The patient felt comfortable to manage her symptoms at home, and was discharged with a urine strainer and urology follow up as needed.

 

References:

American Urological Association-Surgical Management of Stones: AUA/Endourology Society Guideline, http://www.auanet.org/guidelines/surgical-management-of-stones-(aua/endourological-society-guideline-2016).

American Urological Association-Medical Student Curriculum: Kidney Stones, https://www.auanet.org/education/auauniversity/medical-student-education/medical-student-curriculum/kidney-stones.

Airway Corner with Dr. Kaide

Dr. Kaide’s Airway “tip of the month”

There was this hypothetical patient…who was being intubated.  As soon as the patient was paralyzed dark blood came pouring out into the mouth from an upper GI bleed. The resident immediately suctioned a continuous flow of blood from the airway. She could not see any airway structures because of the bleeding.  Now what?

The reason for this post is to add some thoughts to how to trouble shoot a very bad situation in advance so as to avoid trying to be creative in the moment. Under pressure people rarely rise to the occasion but rather regress to the mean…unless the trouble shooting process is thoroughly engrained.

The solution that we used was to introduce an 7-0 ETT without a stylette aimed with the tip down and to slide it along the back of the tongue into the esophagus and blow up the balloon. As soon as it went in, blood spewed out of the ETT. We stuck the yankaur into the ETT. This diverted the blood out of the airway and with a few seconds of suctioning of the mouth, she was able to see cords and successfully pass the ETT into the airway.

LEARNING Points. These are my thoughts, love to hear other thoughts!!

  1. Divert the blood immediately!
  2. Don’t use the stylette as it can be traumatic to the esophagus.
  3. Aim the ETT tip downward to increase the likelihood of an esophageal intubation.
  4. Have dual suction set up.
  5. Preoxygenate like you are in 2017 with NC at 15 LPM and NRB to flush (50 LPM). This means the knob is turned until it can’t be turned any farther. Keep NC on during intubation.
  6. This patient should have started in the ramped position to help use gravity to your advantage and keep passive blood from coming up from the stomach.
  7. Probably should put down an NG before intubation to decompress the stomach…depends on your “pre-test” probability of stomach volume trouble.  NG is NOT contraindicated in suspected variceal bleeding.
  8. Still can’t see? There are 2 holes and you plugged one up. Aim up and blindly put the tube in the only other hole there is. A bougie would be useful in this situation.
  9. Here ind something totally not on the radar…consider digital intubation.
  10. Still can’t get it in? Try blind nasotracheal intubation. You may be able to simulate a breath in the paralyzed patient by having someone compress the chest when you are listening to the ETT.
  11. Still can’t get it in but sats are still OK, consider retrograde intubation. No kit? Use a triple lumen kit because the guide wire is long enough to allow an ETT to be placed. I have done 3 of these on living humans but not recently since the age of video laryngoscopes. I have done a ton on cadavers when teaching in the procedure lab. Easy procedure. If they are desaturating, don’t try retrograde (especially for the first time). It takes a minute or so to do if all goes well.
  12. Digital intubation?
  13. If they are desaturating, you can try bagging even with the ETT still in the esophagus. It takes one person to hold the mask very tightly around the tube to keep the seal. Place one or 2 nasal trumpets to help. Alternatively, you could take the ETT out and bag.
  14. One other trick that has worked for me in the past in this exact situation is to place an ETT into the mouth and have someone squeeze the mouth closed like a purse string around both ETTs and bag the ETT that is in the mouth. Make sure to pinch the nostrils shut too. It actually works! I call this the Gorgas Method, named after Diane Gorgas, one of my now colleagues who taught it to me when I was a resident and she was the associate residency director (1993-96)!
  15. Can’t intubate, can’t oxygenate? This is now a failed airway and proceed to open cric.​

Case Conference Summary, August 16, 2017

Thanks to Dr. Daniel Francescon for putting together the following summary of Rapid Fire Case Conference, August 16th:

Dr. Schirm presents a case of a 47F with the common complaint of elbow pain. It has been worsening for the past three weeks and is exacerbated by movement, especially when lifting objects at her job. She denies any fevers or trauma to the area. Physical exam is significant for point tenderness over the lateral epicondyle with full range of motion. She is neurovascularly intact distally. Dr. Schrim forgoes an X-ray and diagnoses the patient with lateral epicondylitis (tennis elbow).

As it is the most common etiology for those presenting with elbow pain, familiarity with lateral epicondylitis is essential to any emergency physician. Be on the lookout for it in middle-aged men or women engaged in repetitive arm motions, including lifting heavy objects or tools as well as leisure activities (seen in up to 50% of tennis players). Pathophysiology involves remodeling of tendons at lateral epicondyle due to chronic stress. It is a clinical diagnosis but XRs may be obtained for physician or patient concern. Treatment in the ED is placement of a counterforce brace and follow up with PCP or sports med.

Figure 1: Counterforce brace. Courtesy of Wikimedia.org

Dr. Schirm next shares the case of a 25M who presents with actively seizing with vomitus around the mouth. He was found by EMS with a bottle of “minty” smelling liquid lying next to him. Dr. Schirm astutely recognizes this as severe methylsalicylate toxicity due to oil of wintergreen ingestion. Initial Ativan trial did not resolve seizures. While he would ideally avoid placing an ET tube in this ingestion, Dr. Schirm decided to intubate due to concern for airway protection given active seizure and vomitus. Seizing did resolve with periintubation benzodiazepines and propofol sedation and the patient was mechanically ventilated at a rate of 30 breaths per minute. Alkalinization of urine initiated with bicarb bolus and drip and the patient was admitted to the ICU for further management and hemodialysis.

Suspect salicylate toxicity in patients presenting altered with nausea, vomiting, abdominal pain and tinnitus. Salicylates work therapeutically by irreversibly blocking COX-1 and modifying COX-2 resulting in decreased inflammation and decreased platelet aggregation. In higher doses, creates a mixed metabolic acidosis and respiratory alkalosis through simultaneous decoupling of oxidative phosphorylation (increased lactate) and stimulation of respiratory centers (increased ventilation).

Treatment, similarly, is multifactorial. If seizing, IV benzos are preferred. If airway protection is necessary due to seizure/coma, set ventilation at elevated rate to match patient’s minute ventilation and minimize further acidosis (30 is good starting point if minute ventilation unknown). Frequent blood gases are necessary and paralysis should be minimized to prevent CO2 retention. Alkalinization of urine can help with excretion of salicylate. One suggested regimen is boluses 1ml/kg of 8.4% sodium bicarb until pH of >7.45 is achieved. If toxicity is severe enough to require intubation, hemodialysis is indicated.

Dose-related risk assessment:

  • <150mg/kg: minimal symptoms
  • 150-300 mg/kg: mild to moderate intoxication – tachypnea, tinnitus, vomiting
  • >300mg/kg: severe intoxication – AMS, seizures, coma
  • >500mg/kg: potentially lethal

NOTES:

  • Oil of Wintergreen is extremely potent. 1mL of typical solution equates to 1400mg aspirin.
  • Don’t forget to evaluate for coingestions

More information and references:

Life in the Fast Lane – Salicylates

Guidance Document: Management Priorities in Salicylate Toxicity

Dr. Grantham recounts a story of a 65F with a history of atrial fibrillation presenting with palpitations. She has a heart rate of 130 but is otherwise stable. EKG shows irregular rhythm with no discernible p-waves consistent with atrial fibrillation with rapid ventricular response. She has not been taking her blood thinner and the onset of her palpitations is unclear. EKG shown below.

https://lh4.googleusercontent.com/_ydzElakFrWsRJ7uQbqCbqacdW7IdcCjPtbtol4Js8vnsz2m85ChzjVNoRrp6fJ0bxRnHN7LauUyWr3U7o0GHqfIKcd4g7e7U3zXn4-bNajSIMBJrtrV2kwMN-sGMSYCSP1cdQ9dtp4

As the patient is stable, Dr. Grantham effectively rate-controls with diltiazem bolus and drip. This has been shown to be 97% percent effective compared to 50% efficacy of metoprolol. As Dr. Nandam warned, be weary of giving dilt in setting of decreased ejection fraction as this could acutely worsen. Dr. Grantham sets a heart rate goal at <110bpm, noting that there is no significant difference in long-term outcomes for a goal of <110 vs 24h, the patient will require TEE to evaluate for clot prior to electrical cardioversion. Additionally, the patient will require anticoagulation due to increased risk of stroke due to increased risk of clot formation in the fibrillating atrium as well as atrial stunning status post cardioversion. This was deferred to a discussion with cardiology.

Important to evaluate for precipitating factor in Afib with RVR:

PIRATES

Pulmonary disease (COPD, PE)

Ischemia (ACS)

Rhemuatic heart dz (mitral stenosis)

Anemia (high output HF/tachycardia)

Thyrotoxicosis

Ethanol/endocarditis

Sepsis/Sick sinus syndrome

Dr. Grantham’s next story of old people not taking their medication correctly is of a 77M presenting the four days of dark, tarry stools after accidently taking too much of his Coumadin. He was found to have a drop in Hb from 11 to 7.4 and an INR of 10.4. He provided a helpful algorithm for elevated INR, as seen below.

Active Bleeding?
Stop coumadin, give vitamin K with FFP or PCC
No Active Bleeding
INR
3-4.5 Omit next dose, resume at lower dose
4.5-10 Stop warfarin, monitor
>10 Stop warfarin, recheck in 12-24h

Additionally, OSU Guidelines on OneSource provide further management information.

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Vitamin K and PCC were given and the patient was admitted to the ICU for GI bleed. Onset of PCC is 15 minutes. If INR at that time is >1.4, you may re-dose or give FFP. If giving FFP, expect it to last 4-6h. Dr. Cotton also noted that FFP may be superior to PCC in patients with liver failure, as metabolism of PCC by liver is necessary for effect.

Dr. Buck presents a case of a 28F with chest pain that occurred after an episode of vomiting. She does not have any cardiac risk factors and is PERC negative. However, given onset after vomiting, Dr. Buck is concerned about esophageal rupture or Boerhaave’s syndrome.

Esophageal rupture presentation is characterized by acute, severe, unrelenting chest pain that often occurs suddenly after forceful vomiting. Physical exam may be notable for cervical subcutaneous emphysema. Mediastinal emphysema may occur as well. A “crunching” sound during heart beats is known as Hamman’s sign.

Dr. Buck then discussed diagnostic options when there is concern for Boerhaave’s, as seen below:

  • Esophagram provides definitive diagnosis
    • Done first with gastrograffin followed by barium (risk of causing mediastinitis) if negative
  • Chest XR: 90% will have nonspecific abnormalities, including penumomediastinum, abnormal mediastinum contour, ptx, pleural effusion
  • CT chest: may show pneumomediastinum but will not show tear
  • Emergent endoscopy may worsen tear during insufflation

A finding of an esophageal tear is an emergency and management in the ED consists of volume resuscitation, broad-spectrum IV abx and emergent surgical consult.

Her next case was of a 24F with a headache for several weeks. She had been evaluated in the ED over its course and it had proven refractory to multiple headache cocktails. Her exam was unremarkable with a normal neurologic exam and no signs of papilledema. Her only medication was her oral contraceptive and Dr. Buck expressed concern for dural venous sinus thrombosis.

Dural venous sinus thrombosis is an extremely rare condition, making up <1% of all strokes. However, it is a “can’t-miss” diagnosis due to the significant morbidity that it causes in its primarily younger demographic (80% occur in patients <50 years old). Consider it in patients (3x greater risk in females) with persistent headache who are in prothrombotic states, including those taking OCPs, pregnant patients, those under hormone treatment for in vitro fertilization or anyone with underlying coagulation disorder.

Diagnosis of dural venous sinus thrombosis:

  • MRI/MRV is gold standard
  • CT venography: 95% sensitive
  • Non-contrast head CT can show dense vein sign though less sensitive

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Figure 2. Courtesy of ResearchGate.net. Axial T1- (a) and T2-weighted (b) MRI show direct signs of hyperintense thrombus in the superior sagittal sinus replacing the normal flow voids, as well as right frontal cerebral edema from venous congestion (arrowhead, b)

MRI/MRV above showing “delta” sign in superior sagittal sinus.

Treatment for dural venous sinus thrombosis is anticoagulation for 3-6 months if clot was provoked (pregnancy, OCPs, surgery, etc.) and offending agent is removed or 6-12 months if unprovoked. Presence of intracranial hemorrhage is not considered contraindication for anticoagulation. This should be treated like a stroke, with admission to stroke unit if possible as well as neurology and hematology consultations.