Nephrolithiasis Clinical Pathway – Emergency Department

Emergency Department Clinical Pathway for Evaluation/Treatment
of Children with Suspected Nephrolithiasis

Goals and Metrics
Imaging Considerations
RBUS
  • Preferred
  • May not detect very small stones
    • Calyceal, pelvic or ureteral location
  • Identifies anomalies
CT Abd-Pelvis Non-Contrast
  • More sensitive
  • Can detect ureteral stones, stones < 1 mm
  • Requires exposure to low-dose ionizing radiation
  • Consider CT 1st if:
    • Concern for pyelonephritis
    • Weight > 100 kg
    • Severe scoliosis
Child with Suspected Nephrolithiasis
 
 
Triage
 
 

Team Assessment

  • History and Physical
  • Analgesia, IV fluids as indicated
  • Labs as indicated
    • BMP, Phos, CBC
    • UA, Urine Culture, HCG
  • Imaging
    • US Renal and Bladder preferred
    • Consider CT abd and pelvis non-contrast as indicated
 
 
 
 
No Stone Visible on US
  • Secondary Signs of Nephrolithiasis on Ultrasound
  • Pelvicalyceal dilation
  • Ureterectasis
  • Increase in renal size
  • Uroepithelial thickening
Stone Visible on US
 
 
 
 
 
 

No secondary signs
and
Low clinical suspicion

Secondary signs
or
High clinical suspicion

 
 
 
 
CT abd and pelvis for renal stones (non-contrast)
 
 
 
 
 
 
Review differential diagnosis
No stone present
Stone present on CT
 
 
 
 
Non-ureteral stone
Ureteral stone
 
 
 
 
 
 
No concern for infection
Concern for infection
 
 
 
 
  • Discharge
  • Refer to Urology for further evaluation
Urology Consult
 
 
 
 
Discharge Criteria
Admission Criteria
  • Adequate pain control
  • Tolerating PO hydration
  • No concern for infection
  • Concern for infection
    • Fever, UTI, sepsis
  • Any of the following conditions
    • Solitary kidney
    • Bilateral renal obstruction
    • Renal insufficiency
    • Kidney transplant
    • Complex medical history