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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Jul 2, 2017

Emergency management of priapism, hematuria, and interstitial cystitis are discussed with urologist Brian Shaffer.

Warning: the following program contains graphic descriptions of medical procedures. Listener discretion is advised. 

Stuff Adam and Rob have discovered recently and are really digging

Rob

  1. Dermastent
  2. Bounce Bars esp the Cacao Mint. Super tasty and efficient nutrition balls of heavenly delight I use during shifts (and home, and exercise, and so on). 
  3. This Tono-Pen

Adam

  1. Wearing gloves while eating a sandwich
  2. Topical TXA for a persistently bleeding biopsy site in a patient taking rivaroxaban
  3. Nebulized lidocaine for cough. Adam puts 100mg of lidocaine in the nebulizer basin either with or without bronchodilator

Treating Priapism

  1. Patient presents with persistent painful penile erection.
  2. Anesthetize the penis, sterilize the area of corpus cavernosum you are going to drain. How one numbs the penis for this procedure is a matter of great debate, meaning there is no best answer. Some espouse a dorsal penile nerve block while others favor local anesthesia at the site of injection. I prefer local infiltration at the site of injection and have found it to be more reliable than trying to get the whole penis numb.
  3. Mix up a solution of dilute phenylephrine. This is your vasoconstrictive agent. The end goal is to dilute 1mg of pheynylephrine with 10 mL of normal saline (or 9.9 mL if you're a purist). This gives a concentration of 100mcg/mL ( the recommended dose from the American Urologic Association is actually 100-500mcg/mL, giving a significant margin of error). The phenylephrine you have in your department is most likely 10mg/mL, so you will end up drawing a tenth of a mL.  Getting the vasoconstrictive agent mixture correct seems to be one of the more anxiety provoking aspects of this procedure.  There are lots of ways to make your mixture, the most straightforward method I know is to draw up 1mg (0.1 mL) of phenylephrine in a TB syringe. Into that same syringe, draw up 0.9cc of saline. Now you have a total of 1cc total volume. Add that to 9cc of saline and you are at the desired 100mcg/mL concentration. When you've got this task completed, set this syringe to the side. You're going to need it shortly. Pro tip: label the syringe after creating the dilute phenylephrine.
  4. Attach an 18 or 19 g butterfly needle to a large syringe
  5. Inset the butterfly needle into the corpus cavernousum at the lateral base of the penis. It doesn't matter which side, each side connects to the other. Your entry point is either 10 or 2 o'clock. Pull back on the syringe while advancing the needle. Once you get blood back, stop- that is your needle depth for the remainder of the procedure. Pro tip: Even though you might be tempted to use the biggest syringe you can find, like a 60cc behemoth, stick with a 20cc syringe. The bigger syringe might create too much suction, which can ruin the day.
  6. Aspirate blood. This will look thick and dark (chocolate syrup, old motor oil dark). The amount you'll be able to aspirate varies, but it's usually  around 10-20cc.
  7. Keep the butterfly needle in place while you  unscrew the aspiration syringe from the proximal port and replace it with your syringe with dilute pheynlephrine. Better yet, use a 3 way stopcock. On one port, you have your vasoconstrictive agent ready to go. On the other port, you can easily work the replacement of fresh aspiration syringes. Having an assistant for syringe management makes this process much easier (and safer as you're less likely to change the position/depth of the butterfly needle while fiddling about with the syringes)
  8. Inject 1mL of dilute phenylephrine into the penis. Pro tip that's probably not actually a pro tip: After injection, massage the penile shaft to get more diffuse spread of the vasoconstrictive agent. Does this massaging actually improve outcome? Unknown.
  9. The penis may now become flaccid or it may still be tumescent. If the erection does not resolve, repeat steps 6 through 8. This may take several rounds of aspiration and injection of vasoconstrictive agent.
  10. When is the penis flaccid enough that you can stop? Some say when the blood aspirated, others when the penis stays flaccid. There's not an absolute demarcation line, it's more of Justice Potter Stewart's "I know it when I see it."
  11. Milk the penis from tip to base to squeeze out residual blood. The patient can do this as well. Pro tip: After you've finished the above steps, wrap the penis in a compressive bandage like an ace wrap or Coban to prevent reaccumulation of blood.
  12. If you are unable to resolve the priapism with this technique, urology may need to take the patient to the OR

Hematuria

When a patient presents with hematuria, what are the key questions to ask in the ED?

  1. Is there any associated pain? If so, you may be dealing with a stone, infection, etc.
  2. If it is painless, which is the most common situation we see, the big question is whether or not the patient is in CLOT RETENTION. Are they retaining urine or can they pee freely? The test for this is a post void residual bladder scan
  3. If they are peeing blood, but not in clot retention, they can follow up with urology as an outpatient for CT urogram, cystourethrotgam, and advanced urine testing
  4. If they are in CLOT RETENTION, you need to drain the bladder. What often gets placed is a three way catheter. These catheters are great for irrigating the bladder, but may not be sufficient to evacuate clots.
  5. Dr. Shaffer recommends placing a 22 Fr 6 eye catheter. Here's an example of a 6 eye catheter (we have no connection with the company selling these in the link provided)
  6. Once the 6 eye catheter is in, hand irrigate the bladder until there are no clots
  7. If the urine clears (cranberry colored or lighter), pull the catheter and give a voiding trial
  8. If the urine is still bloody, NOW place a 3 way catheter and admit the patient for continuous bladder irrigation. They get admitted to see if they go back into clot retention.
  9. Jess Mason and urologist Eamonn Bahnson have a master class review of placing the difficult foley in the August 2017 edition of EMRAP.

Interstitial cystitis

  1. Evaluate for and treat infection
  2. Manage pain
  3. Make sure they're on an anticholinergic
  4. Follow up with urology