Podcast # 455: Hunting for PeeCP

Author: Michael Hunt, MD

Educational Pearls:

 

  • Like all tests, urine toxicology (utox) screens can have false positives
  • Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
  • Over-the-counter medication such as dextromethorphan also mimic PCP on utox

 

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 432: Hunting for UTIs

Author: Michael Hunt, MD

Educational Pearls:

  • As many as 20% of women in assisted living have asymptomatic bacteriuria
  • This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat
  • True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples
  • Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection

References:

Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407.

Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372.

Summarized by Erik Verzemnieks, MD

Podcast #375: Retrograde Urethrogram

Author:  Jared Scott, MD

Educational Pearls:

  • Blood at urethral meatus in trauma can be a sign of bladder/urethral injury
  • Blind placement of a Foley catheter can make an undiagnosed urethral injury worse
  • Urethral injury is evaluated using a retrograde urethrogram (RUG)
  • If urethra is confirmed to be intact, Foley catheter can be placed to allow additional tests

 

References:

Avery, L. (2012). Imaging of male pelvic trauma. Radiologic Clinics of North America., 50(6), 1201-1217.

Podcast # 344: Foley troubleshooting

Author: Aaron Lessen, MD.

Educational Pearls:

  • When foley is stuck, balloon may not have deflated.
  • Make sure balloon is not in the urethra, which can block drainage.
  • Cut off the port as it may be obstructed.
  • If still not draining, pass guide wire through port to unclog catheter.
  • Other techniques have been described using mineral oil to dissolve, rupturing the balloon through over-inflation, and transcutaneous guided drainage.
  • Crystallization can be a cause of catheter obstruction – sterile water may be a better solution to inflate the ballon than saline when it is first placed.

 

References

Khan SA, Landes F, Paola AS, Ferrarotto L. Emergency management of the nondeflating Foley catheter balloon. Am J Emerg Med. 1991 May;9(3):260-3. PubMed PMID: 2018599.

Hollingsworth M, Quiroz F, Guralnick ML. The management of retained Foley catheters. Can J Urol. 2004 Feb;11(1):2163-6. PubMed PMID: 15003159.

Podcast #309: Return Visits to the ED for UTI

Author: Alicia Oberle, MD

Educational Pearls:

  • Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches.
  • Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate.
  • Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram.

References:

Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

Podcast #295: UTI

Author: Sam Killian, M.D.

Educational Pearls

  • Traditionally, UTI diagnosis has been dependent on urine culture, urinalysis and clinical symptoms. But a recent study casts some doubt on the utility of urine cultures.
  • A study in the Journal of Clinical Microbiology did urine cultures and E. coli PCR in 220 women with UTI symptoms and 86 women without UTI symptoms.
  • In the symptomatic women, 67% had positive E. Coli PCR and 98% had a pathogenic bacteria in their urine culture.
  • In the asymptomatic women, 10% had positive E. coli PCR and/or urine culture.
  • Therefore, this study suggests that urine culture may be of limited utility, since symptoms alone seemed to predict bacteriuria.

References: Burd EM, Kehl KS. A Critical Appraisal of the Role of the Clinical Microbiology Laboratory in the Diagnosis of Urinary Tract Infections. Journal of Clinical Microbiology. 2011;49(9 Supplement). doi:10.1128/jcm.00788-11.

Podcast #294: Rhabdomyolysis

Author: Michael Hunt, M.D.

Educational Pearls

  • Rhabdomyolysis is caused by the destruction of skeletal muscle that leads to the release of myoglobin, which causes renal failure. It presents with pain and weakness in the affected muscle, as well as dark urine.
  • Diagnosis is made with creatinine kinase levels
  • It can happen to extreme athletes after competition, but the most common presentation is in people who fall and are immobilized for long periods of time.
  • Other causes include burns, crush injuries, viral infections (influenza), bacterial infections (Legionella), and medications (statins in adults, propofol in kids)
  • Treatment is aggressive fluids

References: Huerta-Alardín AL, Varon J, Marik PE. Bench-to-bedside review: Rhabdomyolysis ? an overview for clinicians. Critical Care. 2005;9(2):158-169. doi:10.1186/cc2978.

Deep Dive #6: Bacteriuria and the Elderly

Author: Heidi Wald, MD, MSPH 

Associate Professor of Medicine – University of Colorado School of Medicine, Physician Advisor – Colorado Hospital Association

Dr. Heidi Wald explains common misconceptions of UTI’s in elderly patients and provides tips on how to properly identify them.

References:

Trestioreanu , Adi Lador , May-Tal Sauerbrun-Cutler and Leonard Leibovici  Antibiotics for asymptomatic bacteriuria  Cochrane Collaborative Online Publication Date: April 2015.

Trautner BW, Bhimani RD, Amspoker AB, et al. Development and validation of an algorithm to recalibrate mental models and reduce diagnostic errors associated with catheter-associated bacteriuria. BMC Med Inform Decis Mak 2013;13:48.

Trautner BW, Grigoryan L, Petersen NJ, et al. Effectiveness of an Antimicrobial Stewardship Approach for Urinary Catheter Associated Asymptomatic Bacteriuria. JAMA Intern Med 2015.

D’Agata ELoeb MB, and Mitchell.  Challenges in assessing nursing home residents with advanced dementia for suspected urinary tract infections. J Am Geriatr Soc.2013 Jan;61(1):62-6. doi: 10.1111/jgs.12070.

Stone ND, Ashraf MS, Calder J, et al. Surveillance definitions of infections in long-term care facilities: revisiting the McGeer criteria. Infect Control Hosp Epidemiol 2012;33:965-77.

Podcast #216: Roller Coasters and Kidney Stones

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Anecdotal evidence suggests that roller coasters may help with kidney stones.
  • A recent study used a model of a kidney and ureter with different sized stones and put it on Thunder Mountain roller coaster in Disney World.
  • There was “dramatic passage” of the kidney stones at the rear of the roller coaster.

References: Marc A. Mitchell, DO; David D. Wartinger, DO, JD. Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. The Journal of the American Osteopathic Association, October 2016, Vol. 116, 647-652. doi:10.7556/jaoa.2016.128. http://jaoa.org/article.aspx?articleid=2557373