Pocket Emergency Medicine Pdf

Treatment of nephrolithiasis involves emergency management of renal ureteral colic, including surgical interventions where indicated, and medical therapy. The Three Steps to Preparedness 1 DISASTER PREPAREDNESS For Seniors By Seniors Take responsibility to protect your life Prepare NOW for a sudden emergency. GERIATRIC FUNCTIONAL ASSESSMENT An educational exercise with a Standardized Patient Instructor emphasizing functional status assessment and communication skills. Pocket Emergency Medicine Pdf Torrent' title='Pocket Emergency Medicine Pdf Torrent' />Pocket Emergency Medicine Pdf BookApproach Considerations, Emergency Management of Renal Colic, Surgical Care. In general, stones that are 4 mm in diameter or smaller will probably pass spontaneously, and stones that are larger than 8 mm are unlikely to pass without surgical intervention. With MET, stones 5 8 mm in size often pass, especially if located in the distal ureter. The larger the stone, the lower the possibility of spontaneous passage and thus the greater the possibility that surgery will be required, although many other factors determine what happens with a particular stone. Indications and contraindications. The primary indications for surgical treatment include pain, infection, and obstruction. Infection combined with urinary tract obstruction is an extremely dangerous situation, with significant risk of urosepsis and death, and must be treated emergently in virtually all cases. The 2. 01. 6 American Urological Association AUAEndourological Society guidelines provide more specific indications for surgical treatment. The guidelines recommend surgery in the following scenarios 3. Ureteral stones 1. Uncomplicated distal ureteral stones 1. MET. Symptomatic renal stones in patients without any other etiology for pain. I/51wjjzrUvzL.jpg' alt='Pocket Emergency Medicine Pdf Textbook' title='Pocket Emergency Medicine Pdf Textbook' />Pediatric patients with ureteral stones that are unlikely to pass or in whom MET has failed. Pregnant patients with ureteral or renal stones in whom failed observation has failed. General contraindications to definitive stone manipulation include the following Active, untreated UTI. Uncorrected bleeding diathesis. Pregnancy a relative, but not absolute, contraindication. Specific contraindications may apply to a given treatment modality. For example, do not perform ESWL if a ureteral obstruction is distal to the calculus or the patient is pregnant. Surgical options. For an obstructed and infected collecting system secondary to stone disease, virtually no contraindications exist for emergency surgical relief either by ureteral stent placement a small tube placed endoscopically into the entire length of the ureter from the kidney to the bladder or by percutaneous nephrostomy a small tube placed through the skin of the flank directly into the kidney. Many urologists have a preference for one technique or the other. In general, however, patients who are acutely ill, who have significant medical comorbidities, or who harbor stones that probably cannot be bypassed with ureteral stents undergo percutaneous nephrostomy, whereas others receive ureteral stent placement. In one study, investigators found that the routine use of flexible nephroscopy during percutaneous nephrolithotomy PCNL also known as nephrostolithotomy provided advantages over standard PCNL, in which rigid nephroscopy is used. Flexible nephroscopy resulted not only in a higher stone free rate relative to rigid nephroscopy but also in fewer interventions and bleeding, particularly in patients who had calculi with low Hounsfield unit density. In patients who are floridly septic or hemodynamically unstable, a percutaneous nephrostomy is a faster and safer way to establish drainage of an infected and obstructed kidney. In these situations, retrograde approaches to drainage, if used at all, should be reserved for relatively mild cases in which patients are medically stable. Use appropriate urine cultures and antibiotics whenever a UTI is suspected in conjunction with hydronephrosis or renal colic. The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques. Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases. Guidelines are now available to assist the urologist in selecting surgical treatments. The 2. 00. 5 AUA staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone of management this is consistent with the 2. AUAEndourological society guidelines. In the same 2. 01. URS is considered the first line therapy for mid distal ureteral stones that require intervention, although patients should be offered ESWL if URS is declined. With regard to renal stones, the guidelines recommend ESWL or URS to symptomatic patients with nonlower pole stones with a total stone burden 2. PCNL is recommended for symptomatic patients with a total renal stone burden 2. In pediatric patients, URS or ESWL can be offered for ureteral stones that are unlikely to pass or when MET has failed. ESWL or PCNL can be offered to pediatric patients with a total renal stone burden 2. Stent placement. Internal ureteral stents form a coil at either end when the stiffening insertion guide wire is removed. One coil forms in the renal pelvis and the other in the bladder. Stents are available in lengths from 2. F to 8. 5. F. Some are designed to soften after placement in the body others are rather stiff, to resist crushing and obstruction by large stones or external compression with occlusion from an extrinsic tumor or scar tissue. To select the correct size stent, estimates can be made based on the height of the patient, or the ureteral length can be measured. This is best performed by means of a retrograde pyelogram. The distance from the tip of the retrograde catheter to the ureteropelvic junction is measured in centimeters with a tape measure. To account for the average magnification effect of the film, 1. If the result is an odd number, a double J stent one size longer is used. The most common lengths used are 2. The optimal stent width depends on both the relative diameter and course of the ureter and the purpose of the stent. If the patient has a stricture or a tortuous ureter, a stiffer or larger diameter stent is placed if possible. When used for stone disease, stents perform several important functions. Cabs Software'>Cabs Software. They virtually guarantee drainage of urine from the kidney into the bladder and bypass any obstruction. This relieves patients of their renal colic pain even if the stone remains. Over time, stents gently dilate the ureter, making ureteroscopy and other endoscopic surgical procedures easier to perform later. Because they are also quite radiopaque, stents provide a stable landmark when performing ESWL. How To Megaman X4 Pc For. A landmark is particularly important with small or barely visible stones, especially in the ureter, because the ESWL machine uses radiographic visualization to target the stone. However, routine stent placement should not be performed in patients undergoing ESWL, as there is no difference in stone free rates with or without stent placement in these patients. Once large stones are broken up, stents tend to prevent the rapid dumping of large amounts of stone fragments and debris into the ureter called steinstrasse. The stent forces the fragments to pass slowly, which is more efficient and prevents clogging. Stents do have drawbacks. They can become blocked, kinked, dislodged, or infected. A KUB radiograph can be used to determine stent position, while infection is easily diagnosed by urinalysis. A renal sonogram can sometimes be helpful if obstruction is a concern. Questionable cases can be evaluated further using a radiographic cystogram or an IVP. The cystogram is performed by filling the urinary bladder with diluted contrast media through a Foley catheter under gravity pressure. A stent that is unclogged and functioning normally should show free reflux of contrast from the bladder into the stented renal pelvis.