Rosen & Barkin's 5-Minute Emergency Medicine Consult (324 page)

• Antibiotic recommendations for UTI are discussed in the relevant chapters.
  
• Steroids for rapidly progressing glomerulonephropathy should be discussed with a nephrologist.
  

FOLLOW-UP

• Acute renal failure:
  
• Azotemia/uremia/hyperkalemia
  
• Hemodynamic instability
  
• Hematuria with traumatic injuries
  
• Obstructing ureteral stones with evidence of systemic infection or renal failure
  
• Hypertensive emergency
  
• Oliguria/anuria
  
• Pregnant with preeclampsia, pyelonephritis, obstructing nephrolithiasis
  
• Intractable pain
  
• Intolerance of PO fluids and medications
  

• Hemodynamically stable without life-threatening issues
  
• Infected ureteral stones without renal failure or obstruction
  
• Mild hematuria or proteinuria without renal failure
  
• Hematuria:
  
  • Gross hematuria, except in young women with proven UTIs, needs urology follow-up.
    
  • Microscopic hematuria needs repeated U/As and PCP follow-up, and may need urology/nephrology in the future.
    
  • Pregnant patients with possible infections should have close follow-up to ensure treatment success.
    
• Proteinuria:
  
  • Mild cases should be referred to their primary care physician for further workup in an outpatient setting.
    
  • Nephrotic-range proteinuria, as well as proteinuria with renal failure and no alternative explanation, should be referred to a nephrologist promptly.
    

• Missing acute glomerulonephritis in children, either by misdiagnosing as a UTI based on the U/A, or by failing to consider it in the differential is a pitfall.
  
• Spot urine protein/creatinine ratio correlates well with 24 hr urine protein (i.e., ratio of 3.5 is roughly equivalent to 24 hr protein excretion of 3.5 g)
  
• Periorbital edema can be a sign of nephritic syndrome, not just allergic reaction.
  
• Failing to ensure follow-up for asymptomatic hematuria, especially in patients >40 yr is a pitfall.
  

• McDonald MM, Swagerty D, Wetzel L. Assessment of microscopic hematuria in adults.
  Am Fam Physician
  . 2006;73(10):1748–1754.
  
• Naderi AS, Reilly RF. Primary care approach to proteinuria.
  J Am Board Fam Med
  . 2008;21(6):569–574.
  
• Rao PK, Jones JS. How to evaluate ‘dipstick hematuria’: What to do before you refer.
  Cleve Clin J Med
  . 2008;75:227–233.
  
• Wolfson AB, Hendey GW, Ling LJ, et al., eds.
  Harwood-Nuss’ Clinical Practice of Emergency Medicine.
  5th ed. Philadelphia, PA: J.B. Lippincott Publishers; 2009.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Urinary Tract Infection, Adult
  
• Urinary Tract Infection, Pediatric
  
• Preeclampsia/Eclampsia
  
• Renal Failure
  
• Renal Calculus
  

CODES

• 599.70 Hematuria, unspecified
  
• 791.0 Proteinuria
  
• 599.71 Gross hematuria
  

BASICS

• Caused by deficiency of functional factor VIII or factor IX
  
• Lack of functional factor causes partial inactivation of coagulation cascade and impaired hemostasis.
  
• 2 types:
  
  • Hemophilia A: Factor VIII deficiency
    
  • Hemophilia B (Christmas disease): Factor IX deficiency
    
• Symptoms dependent on factor activity:
  
  • 5–30% factor activity (mild hemophilia):
    
    • Bleeding with major trauma or surgery
      
  • 1–5% factor activity (moderate hemophilia):
    
    • Bleeding secondary to trauma/surgery
      
    • Occasional spontaneous hemarthroses (<1 time per month)
      
  • <1% factor activity (severe):
    
    • Spontaneous bleeding from infancy
      
    • May bleed as often as 1–2 times per week, often requiring factor replacement
      
• Complications:
  
  • Death from hemorrhage
    
  • Recurrent joint bleeding leads to joint destruction and loss of function
    
  • Transfusion-transmitted infections (risk reduced with purification of concentrates)
    
  • Development of inhibitors (IgG antibodies to factors), which prevent hemostasis
    

• X-linked recessive, though 1/3 have a spontaneous mutation
  
• Rare disease:
  
  • Hemophilia A: 1 in 5--7,000 males
    
  • Hemophilia B: 1 in 30,000 males
    
• Prevalence of inhibitors: 20% of severe hemophilia A and <5% of severe hemophilia B
  

DIAGNOSIS

• Bleeding:
  
  • Hemarthrosis (most common):
    
    • Knee (most common) > elbow > ankle > shoulder > wrist
      
  • Muscle hemorrhage
    
  • Bleeding from soft tissue lacerations
    
  • Postextraction or oral mucosal bleeding
    
  • Epistaxis (only in severe disease)
    
  • Hematuria
    
  • Intracranial hemorrhage
    
  • GI bleeding
    
  • Pseudotumors (blood cysts)
    

Thorough history and physical exam

• PLT count: Normal
  
• Bleeding time: Normal
  
• PT: Normal
  
• PTT: Increased
  
• Urinalysis: Asymptomatic hematuria (often)
  
• Specific factor assays:
  
  • Factor VIII:Ag (measures quantity): Decreased
    
  • Factor VIII:c (measures activity): Decreased
    
  • vWF:Ag and vWF: Normal
    

Radiographic studies may be required in certain circumstances:

• Head CT to evaluate for intracranial bleed
  
• Renal US/cystoscopy to evaluate excessive hematuria or renal trauma
  
• Abdominal CT to evaluate for retroperitoneal bleeding
  

• Von Willebrand disease
  
• Anticoagulant drugs
  
• Antiplatelet agents
  
• Thrombocytopenia
  
• Hepatic dysfunction
  

TREATMENT

• Control bleeding proximally.
  
• Establish IV access, draw type and screen.
  
• Consider PRBCs for transfusion.
  

• Patients generally know their doses, type of factor, and whether or not they have inhibitors. Have low threshold for factor replacement when they present with any symptom.
  
• Coordinate ED care with patient’s hematologist.
  
• Start replacing factors immediately, even before imaging/consults.
  

• 1 U in 1 mL of normal plasma is considered 100% clotting factor activity.
  
• People without hemophilia have factor levels between 60% and 150%.
  
• Step 1: Determine% activity desired based on location/system involved in bleeding:
  
  • Low to moderate bleeding – want 30–50% activity
    
    • Soft tissue injury/lacerations
      
  • Joint or muscle bleeding (except iliopsoas)
    
  • Moderate to severe bleeding – want 50–100% activity
    
    • GI or GU bleeding
      
    • Major muscle bleeds (iliopsoas)
      
  • Severe to life-threatening bleeding – want 100% activity
    
    • CNS injury/intracranial bleed
      
    • Major bleeding from trauma or postsurgery
      
    • Intra-abdominal/retroperitoneal bleeding
      
    • Throat/neck bleeds compromising airway
      
• Step 2: Calculate factor dose for level of activity desired.
  
  • Factor VIII required (in U) = wt (kg) × 0.5 × (% factor activity desired). 1 IU/kg raises activity by 2%. Give every 12 hr for 1–2 days.
    
  • Factor IX required (in U) = wt (kg) × 1 × (% factor activity desired). 1 IU/kg raises activity by 1%. Give every 24 hr for 1–2 days.
    
  • Factor dose given IV push over 1–2 min