Urine Luck: Improving Diagnosis in the ED
Maria Tama, MD RDMS
13-month-old female presents to the emergency department with fever Tmax 103 for 4 days. Mom reports multiple episodes of watery diarrhea and some URI symptoms. She had intermittent episodes of vomiting over the last 4 days. No medical problems. No daycare or sick contacts. No recent travel.
VS T102.7 HR 138 BP 103/58 RR28 O2 99% Wt: 13.8kg
Gen: crying but consolable by parents
Heent : perrla eomi clear conjunctiva pharynx erythematous mmm tm clear + light reflex no erythema
CVS S1 s2 no murmurs
Lungs cta bilaterally no wheezing or crackles
Abd soft ntnd
Ext From x4
Skin no rashes wwp
Will you give antipyretics and dc since you have a "source"?
Do labs?
CXR? Urine?
Nothing or all of it??
4mo F presents to the ed with an episode of cyanosis that occurred after crying a lot. Mom reports pt was uncomfortable appearing and was crying. Had an episode where her legs went stiff and her lips went blue. Body was limp but denies any full body shaking no eyes rolling back no seizure like activity. Mom reports pt is back to baseline.
VS T 100.6 HR167 BP 90/56 RR32 O2 99% Wt 7lb
Gen: well appearing good perfusion alert awake good suck feeding
Heent: Perrla eomi tm clear pharynx clear
CVS s1 s2 no murmurs
Lungs cta bilaterally
Abd soft ntnd
Ext from x 4
Skin on rashes wwp
Neuro: no focal deficits
What is your work up for this patient?
Does the fever bring you down a separate path??
For this age, I am thinking infectious (with the fever), seizures, cardiac related...
Urinary tract infections
Not all UTIs present the same. Both of these patients above has UTIs which were the cuase of their initial complaints. Symptoms are often nonspecific which can lead to misdiagnosis all together.
Who to test:
Infants (2-24 months )
Symptoms: Fever without source, irritability, poor feeding, vomiting, failure to thrive
Toddlers & Young Children (2–5 years)
Symptoms: Abdominal pain, fever, vomiting, dysuria, urgency, enuresis
Often unable to verbalize urinary symptoms clearly
Urine collection:
Catheterized sample is the preferred route of urine collection. You can start with a bag but if it is positive, you will need a catheterized specimen.
I have found that starting with the urine bag is often not successful, significantly prolongs length of stay in the ED, and often leads to false positives.
Imaging:
Renal and bladder US is indicated after first UTI in 2-24 month pt to rule out structure abnormalities
Treatment:
Cefdinir 14mg/kg once daily
Augmentin 45 mg/kg BID
Keflex 25-100mg/kg/day can be q8-12
When to admit:
Ill appearing
Under 2 months
Poor po tolerance or vomiting ( cannot take oral meds)
Tama's Tips
To catheterize in peds, check the bladder with the US to ensure urine is present. Need minimum 2 cm in AP diameter for successful cath
In females, the urethra is directly above the vagina. NOT HIGHER than that. Use gauze or sterile qtips ,`for assistance, to allow urethra to move anteriorly but covering the vagina. (ASK ME)
In febrile infants <2 years, a UTI with fever is often assumed to be pyelonephritis unless proven otherwise. This is often done to prevent the sequelae like renal scarring in this patient population.
https://uticalc.pitt.edu/- Clinical decision tool on who to test. USE IT!