What is the initial management for a patient presenting to the emergency room with a kidney stone?

Initial Management of Kidney Stone Patients in the Emergency Room

For patients presenting with kidney stones in the emergency room, the provider should perform a screening evaluation including detailed medical and dietary history, serum chemistries, and urinalysis, followed by prompt pain management and appropriate imaging to guide further treatment decisions. 1

Initial Assessment

• Obtain a detailed medical and dietary history to identify conditions, habits, or medications that may predispose to stone disease 1
• Order serum chemistries including electrolytes, calcium, creatinine, and uric acid to identify underlying medical conditions associated with stone disease 1
• Perform urinalysis including dipstick and microscopic evaluation to assess urine pH, indicators of infection, and identify crystals pathognomonic of stone type 1
• Obtain urine culture if urinalysis suggests urinary tract infection or if the patient has a history of recurrent UTIs 1

Pain Management

• Provide prompt pain relief as the main priority in emergency department management 2
• Consider intravenous ketorolac as first-line treatment for acute renal colic in patients without contraindications 3
• For patients with persistent pain despite ketorolac, consider:
  • IV morphine (0.1 mg/kg) 2, 4
  • IV ketamine or ketofol (combination of ketamine and propofol) which may provide superior pain relief with fewer opioid-related side effects 2, 4

Imaging Studies

• Obtain imaging studies to quantify stone burden and guide treatment decisions 1
• Options include:
  • Non-contrast CT scan of the abdomen and pelvis (most sensitive diagnostic modality) 5
  • Ultrasound of the kidneys, ureters, and bladder (alternative imaging option, especially useful to avoid radiation exposure) 5
  • Plain X-ray (KUB) may be used for follow-up of radiopaque stones 6

Treatment Decision-Making

• Treatment approach depends on stone size, location, and patient factors 6, 5

• Approximately 80% of patients will pass their stone spontaneously within 3 days 5

• For stones likely to pass spontaneously:

  • Provide adequate pain control 2, 3, 4
  • Consider medical expulsive therapy 5
  • Ensure adequate hydration with a goal of 2-3 liters of fluid per day 6

• For patients requiring intervention (approximately 20% of cases) 5:

  • Consult urology for potential procedures such as:
    • Lithotripsy for stones in the ureter or kidney 6
    • Litholapaxy for larger bladder stones 6
    • Surgical removal and/or stent placement for obstructing stones 3

Stone Analysis and Prevention

• When a stone is available, obtain stone analysis at least once 1
• Stone composition (uric acid, cystine, or struvite) may implicate specific metabolic or genetic abnormalities 1
• For high-risk or recurrent stone formers, consider additional metabolic testing 1
• Provide prevention strategies including:
  • Increased fluid intake to achieve urine volume of at least 2.5 liters daily 1, 6
  • Dietary modifications, particularly reduction in animal protein and salt content 6

Follow-up Recommendations

• Schedule follow-up with urology or nephrology for comprehensive stone management 1
• For patients with recurrent stones, consider 24-hour urine collection for metabolic evaluation 1
• Monitor patients with struvite stones for reinfection 1