RCP – The pee or not the pee: so many questions!

The pee or not the pee: so many questions!

Resident Clinical Pearl (RCP) – May 2017

Jacqueline MacKay, R3 FMEM, Dalhousie University, Saint John, New Brunswick

 

The case: 

A 16-month old girl with a history of fever of 39 degrees and slightly decreased oral intake for three days. She has no other symptoms of note and is a healthy, fully immunized child. Her vital signs are stable and her temperature is 37.9 after having some Advil at triage. After a careful head-to-toe examination, you note that she looks extremely well and you aren’t able identify a source for the infection.

 

Question:

Could this be a UTI? What investigations would be appropriate?

 


The overall prevalence of UTI in febrile infants age 2-24 months who have no apparent source for fever is 5%. There are some groups with higher than average risk of UTI and these groups can be identified. Additionally, the presence of another source of infection (based on clinical history and physical exam) reduces the likelihood of UTI by half.


 

Individual Risk Factors: Girls Individual Risk Factors: Boys

Caucasian race

Age < 12 months

Temperature 39 degrees or greater

Fever for 2 or more days

Absence of another source of infection

Nonblack race

Temperature 39 degrees or greater

Fever for 24 hours or more

Absence of another source of infection

 


 

In girls age 2-24 months:

  • 1 risk factor: probability of UTI 1% or less
  • 2 risk factors: probability of UTI 2% or less

 

In boys age 2-24months:

  • uncircumcised: probability of UTI exceeds 1% even in the absence of other risk factors
  • circumcised with 2 risk factors: probability of UTI 1% or less
  • circumcised with 3 risk factors: probability of UTI 2% or less

 

The probability of UTI increases with the addition of more risk factors, and some of the factors (such as fever duration) may change during the course of the illness, increasing the probability of UTI.

 

Approximately half of clinicians consider a more than 1% risk of UTI sufficient for further investigation and treatment if UTI is found, to prevent spread of infection and renal scarring.

 


 

Recommendations:

  1. If the clinician determines the febrile infant to have a low (<1%) likelihood of UTI, then clinical followup monitoring without testing is sufficient.
  2. If the clinician determines that the febrile infant is not in a low risk group (>1% risk) then there are two options: obtain a urine specimen through catheterization or suprapubic aspirate for urinalysis and culture; or to obtain a urine specimen through the most convenient means and perform a urinalysis. If the urinalysis suggests UTI (positive leukocyte esterase or nitrites, or microscopic bacteria or leukocytes), then a urine specimen should be obtained through catheterization or suprapubic aspirate.

 


 

Caveats:

  1. A negative urinalysis does NOT rule out UTI with certainty in children; however it is reasonable to monitor the clinical course without initiating antibiotics.
  2. Urine from a specimen bag CANNOT be used for culture to document UTI due to high risk of contamination.

 


 

Case conclusion:

A bag specimen was obtained for urinalysis, which was negative. After discussion with the parents, no antibiotics were prescribed and close followup was available. The child’s fever resolved within 24 hours. The urine culture was also subsequently negative.

 


Reference:

American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management; Roberts KB. Urinary tract infection: Clinical practice guideline for diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(

Continue Reading

SJRHEM @Whistler CAEP 2017

Continue Reading

ED Rounds – Oral Rehydration in Children

Pediatric Dehydration and Oral Rehydration

ED Rounds Presentation by: Dr Paul Page


 

  • Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
  • Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.

American Family Physician article (2009) – Diagnosis and Management of Dehydration in Children


 


SJRHEM Guideline

Hydration Guidelines for Pediatric Patients with Vomiting and/or Diarrhea

 


View/Download Full Presentation below:

Download (PDF, 817KB)

Continue Reading

ED Rounds – Ortho Clinic Pathway

ED Rounds – Ortho Clinic Pathway

ED Rounds Presentation by Dr Paul Keyes

 


 

A personal perspective on system review and pathway re-engineering…

 


Rationalization of Process

  • —Every consult is entered by ERP into I3 and printed to accompany copy or ED chart and is placed in clinic book, with a patient sticker placed on clinic appointment sheet.
  • —Non-urgent consults are faxed to orthopedic surgeons offices for triage and cue placement with all other primary care referrals
  • —If subspecialty specific consult requested, then this is faxed to the orthopod of choice’s office. If urgent, then the orthopod on call will sort/laterally refer consult in clinic that week

Outcomes

  • —Collaborative approach ED and ortho
  • —Single process for all orthopedic referrals
  • —Identical sorting of: In ED, Clinic, Ortho office/subspecialty referrals
  • —Legible, billable consults
  • —Timely and appropriate consultations/assessments
  • —Orthopod flexibility as to site of consultation/clinic
  • —Appropriate chain of responsibility from Consult to consultant evaluation

 

Download (PDF, 3.8MB)

 

Continue Reading

EM Reflections – May 2017

Thanks to Dr Paul Page for his summary

Edited by Dr David Lewis

 

Top tips from this month’s rounds:

  1. DVT – Anticoagulation Bridging… when is it needed?
  2. Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?
  3. Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

 


DVT – Anticoagulation Bridging… when is it needed?

Consider the type of anticoagulation best suited for your patient. Remember warfarin needs bridging until therapeutic INR is achieved.  Ensure that patients discharged after hours have a robust plan for follow up and enough supply until follow up occurs.

Outpatient Management of Anticoagulation Therapy – American Family Physician 2013

 

For Warfarin therapy in DVT, Thrombosis Canada recommends:

Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.

 

Bridging is not required when prescribing a Direct Oral Anticoagulant (DOAC) e.g Apixaban or Rivaroxaban.

 

Thrombosis Canada tool to support decision making for Anticoagulation therapy in DVT

Management of DVT:

General measures:
Unless compression ultrasound (CUS) is rapidly available, patients with moderate-to-high suspicion of DVT (except those with a high risk of bleeding) should start anticoagulant therapy before the diagnosis is confirmed.  Imaging confirmation should be obtained as soon as possible.
Outpatient management is preferred over hospital-based treatment unless there is an additional indication for hospitalization.
Initial treatment should have an immediate anticoagulant effect. Therefore, warfarin monotherapy is not appropriate initially.

Treatment Regimens:

Depending on the clinical presentation, one of following regimens should be used for the initial 3 months:

  • Full-dose low molecular weight heparin (LMWH) overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Full-dose IV heparin overlapping with warfarin for at least 5 days and until the INR is at least 2.0 for at least 2 days.
  • Apixaban 10 mg PO BID for 1 week before reducing dose to 5 mg PO BID.
  • Rivaroxaban 15 mg PO BID for 3 weeks before reducing dose to 20 mg PO once daily.
  • Full-dose SC LMWH or IV heparin for at least 5-10 days before switching to dabigatran 150 mg PO BID or to edoxaban 60 mg PO once daily.
  • Full-dose LMWH alone without switching to an oral anticoagulant.
  • Full-dose LMWH for the 1st month or so before switching to a DOAC or warfarin.

 


Anticoagulated elderly patient with minor trauma. Can we rely on a recent INR?

 

Elderly patients on warfarin presenting with minor trauma are commonly seen in the ED.  Many will have been on warfarin for a prolonged period and will have stable INRs. However we can not rely on a previous INR level when assessing the current presentation. Consider the following rational:

  • Why did the patient fall?
  • Do they have a concomitant illness?
  • Are they compliant with their medication?
  • Have they been prescribed or are you considering prescribing new medication that may interact with warfarin?

Clinically Significant Drug Interactions

Anticoagulated patients frequently re-attend the ED with complications of bleeding after discharge following minor injury e.g enlarging hematoma, blood soaked dressings, missed internal bleeding, mobility failure. Consider whether admission for observation may be more appropriate than discharge in this group of patients. For those discharge ensure that they have close support and clear advice on when to return.

Practical tips for warfarin dosing and monitoring – Cleveland Clinic Journal

 

See this recent Medical Student Pearl on Reversal of Anticoagulation in the ED

Medical Student Clinical Pearl – Reversal of Anticoagulation in the Emergency Department

 


 

Abdominal pain in an elderly patient. Does a nonspecific exam and normal vitals exclude serious illness?

Elderly patients presenting to the ED with acute abdominal pain should be considered extremely high risk. Published series have reported mortality rates approaching 10% (https://www.ncbi.nlm.nih.gov/pubmed/7091511)

Presentations can be delayed, physical exam can be innocuous, lab results can be misleading. The risk of serious pathology is much greater and the outcome of delayed diagnosis can be significant.

Abdominal emergencies in the geriatric patient – Int J Emerg Med. 2014; 7: 43.

 

 

An excellent post from ALIEM – 10 Tips for Approaching Abdominal Pain in the Elderly

After seeing your fifth young patient of the day with chronic pelvic pain, constipation, and irritable bowel syndrome, it is easy to be lulled into the mindset that abdominal pain is nothing to worry about. Not so with the elderly. These 10 tips will help focus your approach to atraumatic abdominal pain in older adults and explain why presentations are frequently subtle and diagnoses challenging.

 

Erect CXR – Abdominal Series – Free air under diaphragm in perforated bowel

 

Bottom Line –

Elderly patients with abdominal pain are at a much greater risk of serious pathology and require an extremely thorough assessment before (if ever) discharging with a rule-out diagnosis e.g constipation, gastro, abdo pain NYD etc.

 

Continue Reading

PoCUS – Measurements and Quick Reference

Developed by Dr. Heather Flemming as part of her PG PoCUS Elective at SJRHEM.

A useful Point of Care Ultrasound (PoCUS) guide to common normal values, measurements, pathological values and quick reference tips. A pdf version is also provided in this post which can be downloaded, printed and attached to your ultrasound machine for easy access.

 

 

 


 


Download (PDF, 1017KB)

 

Continue Reading