1. What is your preferred pain regimen in acute renal colic? What do you like to give for home pain control?
2. When do you use ED ultrasound? If it shows hydronephrosis, how does this affect your management?
3. Do you give alpha-blockers to aid stone expulsion (tamsulosin or terazosin)?
4. Which patients do you CT? Which patients do you not CT?
1. Ketorolac, hydromorhpne (ED), vicodin, motrin (home)
2. young, nontoxic, those who have undergone multiple CTs / as long as creatinine is ok and and no concomitant UTI, d/c home
4. CT those with first time stone, patients greater than 50ish if no recent imaging to exclude AAA, toxic appearing / no CT – see #2
1. Pain meds – dialudid and ketorolac up front, NSAIDs and vicodin for hone
2. US useful in folks with history of renal colic who you are trying to avoid radiation in. If hydronephrosis is appreciated we get urology involved
3. Tamulosin is recomend and started in the ED
4. We CT first time with stone (or likely stone) and if patient is sick – fever, impaired renal function to suggest infected stone or renal damage due to obstruction
1. IV Narcotic + IV NSAID in ED; PO Motrin + PO Narcotic at discharge.
2. I use it in the young, those with good pain control, want to confirm my suspicions, especially if they’re the 10% without blood in their urine.
3. I don’t. This is the best study I know of (blinded) and showed no benefit. This is a really crappy systematic review that showed benefit. The EM literature overall doesn’t really show benefit; the urology literature does. Referral bias.
4. If they’re classic, and I can control their pain, I don’t CT. If they’re classic but their pain keeps returning for more than several rounds of IV pain control, then I CT, concerned they either have a very large stone or a very proximal stone. If they’re not completely classic and old, I frequently CT. I also use bedside ultrasound to look at their aorta.
If someone can explain to me WHY they “CT all first-time stones,” I’d love to know, because I’ve never understood that policy. Frequently the answer I get is, “To make sure I’m not missing something else,” but in a young person, things like renal cancer will frequently present differently and will either come back or get a follow-up imaging study, and things like renal artery/vein thrombosis or renal infarct are going to require IV contrast to see.
1 – Dilaudid initially until stone size known – if non-surgical case then toradol 30 IV and 30 IM, Percocet and Phenergan for home
2 – Depends if US is available – usually not here late at night and Pt in severe pain (no position of comfort and heavy heaves)
3 – Flomax has been helpful to M/F Pt’s with 4mm and less
4 – CT those with first time stone, patients greater than 50ish if no recent imaging to exclude AAA and other abd issues in the differential, if hx shows large multiple stones with concern for hydro, toxic appearing
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