What is the best course of treatment for a patient with a history of kidney stones, presenting with excruciating low back and side pain, radiating to the left side, difficulty breathing, severe nausea, hypotension (low blood pressure), and no urinary symptoms, after lifting a heavy object earlier in the day?

Management of Suspected Kidney Stone with Hypotension in the Emergency Department

Critical First Step: Rule Out Life-Threatening Abdominal Aortic Aneurysm

This patient requires immediate vascular imaging to exclude ruptured abdominal aortic aneurysm (AAA) before assuming kidney stone as the diagnosis. The combination of severe back/flank pain after lifting, hypotension (94/70), difficulty breathing, and severe nausea raises critical concern for AAA rupture, which can present identically to renal colic but is immediately fatal without emergency surgery.

Why AAA Must Be Excluded First

• The hypotension (BP 94/70) is the red flag that distinguishes this presentation from typical renal colic—kidney stones do not cause hypotension unless complicated by sepsis with fever, which this patient lacks 1
• Lifting a heavy object can trigger AAA rupture, and the pain radiating to the left side is consistent with retroperitoneal hemorrhage
• The inability to find a comfortable position and difficulty breathing suggest hemodynamic compromise, not simple renal colic
• Immediate hospital admission is mandatory for patients with shock, which this patient demonstrates with hypotension 1

Immediate Actions in the ER

• Obtain stat CT angiography of the abdomen/pelvis with IV contrast to visualize the aorta and exclude rupture
• Establish large-bore IV access (two lines) and initiate fluid resuscitation
• Type and crossmatch blood products
• Obtain stat complete blood count, basic metabolic panel, and lactate
• Contact vascular surgery immediately if AAA rupture is confirmed

If AAA Is Excluded: Proceed with Kidney Stone Management

Urgent Assessment for Obstructive Pyelonephritis

• If sepsis and/or anuria are present, urgent decompression via percutaneous nephrostomy or ureteral stenting is mandatory before definitive stone treatment 2
• Check temperature, white blood cell count, and CRP to evaluate for infection 2
• Assess renal function with serum creatinine and check for anuria or bilateral obstruction 2
• Obtain urine culture before any intervention 2

Pain Management Protocol

• Administer intramuscular diclofenac 75 mg as first-line therapy, which should provide relief within 30 minutes and is superior to opioids 1
• NSAIDs (diclofenac, ibuprofen, or metamizole) are the definitive first-line analgesic for acute renal colic, not opioids, as they decrease ureteral smooth muscle tone and spasm 2, 1
• Reserve opioids (morphine with cyclizine) only if NSAIDs are contraindicated due to cardiovascular disease, gastrointestinal comorbidities, hypertension, renal insufficiency, heart failure, or peptic ulcer risk 1
• Administer anti-emetics for nausea control 2

Diagnostic Imaging

• Obtain noncontrast CT scan of abdomen/pelvis (once AAA excluded) to confirm stone presence, size, and location 1
• Imaging within 7 days is required to quantify stone burden if not done emergently 1

Conservative vs. Surgical Management Decision

• For stones ≤10 mm without complications, conservative management with medical expulsive therapy is appropriate if pain becomes well-controlled, sepsis is absent, and renal function is adequate 1

• Prescribe tamsulosin (alpha-blocker) for medical expulsive therapy, particularly for stones >5 mm in the distal ureter 1

• Maximum duration of conservative treatment is 4-6 weeks from initial presentation, with mandatory periodic imaging to monitor stone position and hydronephrosis 1

• For stones >10 mm or 12 mm, surgical intervention is required as spontaneous passage will not occur 2

• Ureteroscopy (URS) is the recommended first-line surgical intervention for stones >10 mm 2

• For renal pelvis or upper/middle calyx stones (10-20 mm), flexible ureteroscopy is first-line treatment 2

Initial Laboratory Workup

• Obtain urinalysis with dipstick and microscopic evaluation to assess urine pH, infection indicators, and identify crystals 1
• Order serum chemistries including electrolytes, calcium, creatinine, and uric acid 1
• Send any passed stone for compositional analysis, as composition directs specific preventive measures 1

Supportive Care Instructions

• Instruct the patient to drink fluids targeting urine output of at least 2.5 liters daily to promote stone passage 1
• Have the patient void into a container or tea strainer to catch stones for analysis 1

Common Pitfalls to Avoid

• Do not assume kidney stone without excluding AAA in a hypotensive patient with back pain after lifting—this is a fatal mistake
• Do not use opioids as first-line therapy—NSAIDs are superior and avoid dependence risks 1
• Do not delay admission for fever with obstruction—this represents sepsis requiring urgent drainage 1
• Do not restrict dietary calcium in stone formers, as this paradoxically increases oxalate absorption and stone risk 3