From the Guidelines
Emergency room precautions for nephrolithiasis should prioritize pain management, hydration, and diagnostic testing to prevent complications and improve patient outcomes. The management of nephrolithiasis in the emergency room setting is crucial to prevent potential complications such as ureteral obstruction, hydronephrosis, and infection 1.
Key Considerations
- Administer analgesics promptly, with first-line options including NSAIDs such as ketorolac or indomethacin, which reduce ureteral pressure and inflammation.
- Ensure adequate hydration with IV fluids if the patient is unable to maintain oral intake, typically normal saline at maintenance rates.
- Obtain urinalysis to check for hematuria, pyuria, and signs of infection, and perform imaging studies such as non-contrast CT scan, ultrasound, or KUB X-ray to confirm stone presence, size, and location 1.
Diagnostic Testing
- Non-contrast CT scan is the gold standard for diagnosing nephrolithiasis, but ultrasound or KUB X-ray may also be used, especially in patients with contraindications to CT scans.
- Imaging studies help determine the size and location of the stone, which are important factors in deciding the need for invasive management 1.
Consultation and Discharge
- Consult urology for stones >5mm, complete obstruction, infection, intractable pain, or solitary kidney.
- Patients with smaller stones (<5mm) without complications can often be discharged with oral pain medications, anti-emetics, alpha-blockers like tamsulosin to facilitate stone passage, and instructions to strain urine to collect passed stones for analysis.
Monitoring and Follow-up
- Monitor vital signs, particularly for signs of infection like fever or tachycardia, which may indicate complicated urolithiasis requiring urgent intervention.
- Follow-up with a urologist is essential to ensure the stone has passed and to prevent future episodes.
From the Research
ER Precautions for Nephrolithiasis
- The primary care physician has a responsibility not only to recognize and treat acute stone passage but to ensure that the patient with recurrent stones has metabolic evaluation and appropriate preventive care 2.
- Renal colic is typically severe, radiates to the groin, is associated with hematuria, and may cause ileus 2.
- About 90% of stones that cause renal colic pass spontaneously 2.
- The patient with acute renal colic should be treated with fluids and analgesics and should strain the urine to recover stone for analysis 2.
- High-grade obstruction or failure of oral analgesics to relieve pain may require hospitalization; a urinary tract infection in the setting of an obstruction is a urologic emergency requiring immediate drainage, usually with a ureteral stent 2.
Management of Nephrolithiasis
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are amongst the most commonly used drugs for renal colic 3.
- NSAIDs may reduce pain in adult patients with renal colic compared to placebo 3.
- Alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events 4.
- Patients treated with alpha-blockers may experience shorter stone expulsion times, may use less diclofenac, and likely require fewer hospitalisations 4.
Prevention of Nephrolithiasis
- High fluid intake is a mainstay of prevention 2.
- Metabolic evaluation will indicate other appropriate preventive measures, which may include dietary salt and protein restriction, and use of thiazide diuretics, neutral phosphate, potassium citrate, allopurinol, and magnesium salts 2.
- Dietary calcium restriction may worsen oxaluria and negative calcium balance (osteoporosis) 2.