Kidney Stone Pain

[Doczilla]

ERDoc, what is your opinion on using maxeran (Metoclopramide) for the treatment of migraines? I get the odd nasty migraine, and my doc has given me an Rx for maxeran, but I haven't had the need to try it yet.

I'm coming late to the discussion as usual. EM:RAP did a program within the last 2 years about treatment of migraines. The American Academy of Neurology recommends the following for treatment of acute migraine headache in the emergency department: metoclopramide (Reglan), prochlorperazine (Compazine), or droperidol. Something about the anti-dopaminergic action. I've had excellent results treating people with reglan, IV fluid, and toradol for migraines.

As far as pain control for kidney stones, I don't see a big advantage of one narcotic over another, so long as they are properly dosed. Morphine, fentanyl, dilaudid, demerol, whatever.

Toradol, as an NSAID, is an excellent choice, as the prostaglandin inhibition decreases ureteral spasm. I typically use this in concert with morphine and zofran or phenergan. Going home, they get percocet, motrin, phenergan or zofran, and flomax. Across the pond, steroids (prednisone, methylprednisolone) are used instead of or in conjunction with NSAIDs.

'zilla

[zzyzx]

Should we be giving a fluid bolus to patients with kidney stones? I got a liter of fluid from the ER when I had my kidney stone a few years ago. Most medics I know give fluids to "flush" the stone out, but does it really work? From what I understand, that treatment is controversial.

[8877bpm]

I have migrains, they use DHE and stemetil with me. Anybody ever hear of that?

I have co-worker now who just diagnosed with kidney stone, his is 5mm big, he's in much pain. He takes Torodol but it doesn't do notting for him.

[ladybear]

I have migrains, they use DHE and stemetil with me. Anybody ever hear of that?"

Nope

"I have co-worker now who just diagnosed with kidney stone, his is 5mm big, he's in much pain. He takes Torodol but it doesn't do notting for him.

cause the stone is probably too big to go down the tube.. he might need to be evaluated by a specialist to see if he needs to have lithotripsy done and to see if he's got other problems going on secondary to the stone.

[Doczilla]

I have migrains, they use DHE and stemetil with me. Anybody ever hear of that?

I have co-worker now who just diagnosed with kidney stone, his is 5mm big, he's in much pain. He takes Torodol but it doesn't do notting for him.

Stemetil is a brand name for prochlorperazine, or compazine. This is, as I stated before, standard treatment.

DHE (dihydroergotamine) is a vasoconstrictor. It's actions are similar to those of the triptans: Imitrex, Relpax, Zomig, etc. This is another well-recognized and accepted treatment.

As far as kidney stones go, we'll usually give stones a chance to pass for a couple of weeks before doing lithotripsy, as long as there is no sign of UTI. Studies of Flomax in kidney stones show very high spontaneous pass rates with stones up to 10mm.

'zilla

[Eydawn]

10mm? You mean a full CENTIMETER?

*cringes* OWWW.....

Sorry. Had to say it. I'm still in shock lol!

Wendy

CO EMT-B

[Doczilla]

Should we be giving a fluid bolus to patients with kidney stones? I got a liter of fluid from the ER when I had my kidney stone a few years ago. Most medics I know give fluids to "flush" the stone out, but does it really work? From what I understand, that treatment is controversial.

You're right, it is controversial. In theory, the fluid bolus will help increase urine output and "flush" the stone. In theory, the ureter is blocked, and increasing UOP will increase hydronephrosis and pain. Neither has really been proven as far as I know. A 2006 study in the Journal of Endourology (how could I have been missing this journal all these years?) showed no difference in pain scales or stone passage rates between those receiving 2 L saline bolus over 2 hours or 20cc/hr, essentially KVO. A 2005 Cochrane review found no credible evidence of benefit of aggressive hydration or diuretics to increase UOP.

I give a fluid bolus if the urine looks concentrated on UA (high spec grav) or if they have been vomiting a lot and might be dehydrated. Since I usually give good hefty doses of narcotics for kidney stones, a little fluid to prevent hypotension is not a bad thing. Bottom line, I don't do it routinely, but sometime will. I don't think there is any reason to get real excited about it either way.

'zilla

[firedoc5]

In the past I've had DHE45 (I guess the same as DHE mentioned). It didn't' help the pain but it did help my eye sight to come back.

I know a lot swear by Toroidal, but what about those of us who can't have it? Or any kind of Nsaid? Talk about sicker than a dog with no pain control. Retching vomiting, stomach cramps, etc. I'm usually limited to Demerol and Visteral. Some docs don't like it but...