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ER42 Emergency Medicine
Ophthalmologic Emergencies
Toronto Notes 2019
Kidney Stones
• 80%Calciumoxalate • 10% Struvite
• 10% Uric acid
Obstruction + Infection
= Urological Emergency Urgent urology consult
Indications for Admission to Hospital
• Intractable pain
• Fever (suggests infection) or other
evidence of pyelonephritis
• Single kidney with ureteral obstruction
• Bilateral obstructing stones
• Intractable vomiting
• Compromised renal function
Nephrolithiasis (Renal Colic)
• seeUrology,U18
Epidemiology and Risk Factors
• 10%ofpopulation(twiceascommoninmales)
• recurrence50%at5yr
• peakincidence30-50yrofage
• 75%ofstones<5mmpassspontaneouslywithin2wk,largerstonesmayrequireconsultation
Clinical Features
• urinaryobstruction→upstreamdistentionofureterorcollectingsystem→severecolickypain • maycomplainofpainatflank,groin,testes,ortipofpenis
• writhing,N/V,hematuria(90%microscopic),diaphoresis,tachycardia,tachypnea
• occasionallysymptomsoftrigonalirritation(frequency,urgency)
• fever,chills,rigorsinsecondarypyelonephritis
• peritonealfindings/anteriorabdominaltendernessusuallyabsent
Differential Diagnosis of Renal Colic
• acuteuretericobstruction
• acuteabdomen:biliary,bowel,pancreas,AAA
• urogynecological:ectopicpregnancy,torsion/ruptureofovariancyst,testiculartorsion • pyelonephritis(fever,chills,pyuria,vomiting)
• radiculitis(L1):herpeszoster,nerverootcompression
Investigations
• CBC:elevatedWBCinpresenceoffevermaysupportaninfectiouscause • electrolytes,Cr,BUNtoassessrenalfunction
• U/A:R&M(WBCs,RBCs,crystals),C&S
• non-contrastspiralCTisthestudyofchoice
• abdominalU/Smaydemonstratestone(s),hydronephrosis(considerinfemalesofchildbearingageorif patient has another contraindication to CT scanning), debris in the collecting system, reduced cortical vascularity, abnormal renal parenchyma
• AXRwillidentifylargeradioopaquestones(calcium,struvite,andcystinestones)butmaymisssmaller stones, uric acid stones, or stones overlying bony structures; consider as an initial investigation in patients who have a history of radioopaque stones and similar episodes of acute flank pain (CT necessary if film is negative)
• strain all urine for stone analysis
Management
• analgesics:NSAIDs(usuallyketorolac[Toradol®],preferableoveropioids),antiemetics,IVfluidsif indicated
• urologyconsultmaybeindicated,especiallyifstone>5mm,orifpatienthassignsofobstructionor infection
• α-blocker(e.g.tamsulosin)maybehelpfultoincreasestonepassageinselectcases
Disposition
• mostpatientscanbedischarged
• ensurepatientisstable,hasadequateanalgesia,andabletotolerateoralmedications • mayadvisehydrationandlimitationofprotein,sodium,oxalate,andalcoholintake
Ophthalmologic Emergencies
• seeOphthalmology,OP5
History and Physical Exam
• patientmaycomplainofpain,tearing,itching,redness,photophobia,foreignbodysensation,trauma
• mechanismofforeignbodyinsertion–ifhighvelocityinjurysuspected(welding,metalgrinding,metal
striking metal), must obtain orbital X-rays, U/S, or CT scan to exclude presence of intraocular metallic
foreign body
• ask about sexual partners and exposure of eye(s) to bodily fluids (semen, urine, blood, vaginal fluids,
saliva, etc.)
• visualacuityinbotheyes,pupils,extraocularstructures,fundoscopy,tonometry,slitlampexam
Management of Ophthalmologic Foreign Body
• copiousirrigationwithsalineforanyforeignbody
• removeforeignbodyunderslitlampexamwithcottonswaborsterileneedle
• antibiotic drops qid until healed
• patching may not improve healing or comfort – do not patch contact lens wearers
• limituseoftopicalanesthetictoexaminationonly(theevidenceforthisismixed;ifuncertain,ask
ophthalmology)
• considertetanusprophylaxis
• ophthalmologyconsultifglobepenetrationsuspected
Visual acuity is the “vital sign” of the eyes and should ALWAYS be assessed and documented in both eyes when a patient presents to the ER with an ophthalmologic complaint