Diagnosis 211

The Use of Guidelines and Algorithms

The first step in the management of urologic emergencies is to recognize the clinical significance. One must distinguish among genuinely life-threatening problems such as urosepsis or kidney rupture, urgent problems such as testicular torsion, and merely troublesome conditions such as cystitis in a healthy young woman. This maybe more easily said than done. The practitioner is challenged both by the broad spectrum of urologic emergencies and by the even more numerous possible diagnoses mimicking urologic symptoms. For example, a patient with a long history of renal colic may present with acute flank pain, tachycardia, tachypnea, and hypotension. If renal ultrasound is normal (lack of upper tract dilatation) and urinalysis reveals no microhematuria, abdominal ultrasonography and/or computed tomography (CT), as indicated in a diagnostic algorithm, will lead to the correct diagnosis of ruptured abdominal aneurysm.

A useful source of immediate, compact information for clinicians is found in published clinical guidelines (e.g., from the European Association of Urology

[EAU][Lynch et al. 2005], the American Urological Association [AUA][Montague et al. 2003], or others often based upon the classification for urologic trauma formulated by the American Association for the Surgery of Trauma [Baker et al. 1974; Moore et al. 1989]). Most preferable are guidelines classified by the level of evidence: S1 guidelines representing an informal consensus of experts, S2 a formal consensus, and S3 a formal consensus adhering to evidenced-based medicine, with the elaboration of clinical algorithms. Guidelines in this form are widely used in other fields such as emergency medicine (e.g., cardiovascular resuscitation, initial management of trauma patients) and are increasingly used in urology.

Algorithms lead the doctor through the different potential situations arising during a urologic emergency and communicate in a clear and rapid way how to proceed to the next step. Because they are presented in a stepwise fashion and are logical, they are often easy to memorize. The branching design of algorithms creates decision trees, and the management pathway cannot be continued until the proper test is ordered or the diagnostic solution found. Algorithms therefore provide what is essential and unique to emergency medicine: a simultaneity of diagnosis and therapy.

The Emergency Setting

The emergency setting is characterized by continuous and rapid changes in the patient, and thus the assessment can seldom be deemed complete. Accordingly, repeated checks of the patient and of the working hypothesis are warranted. It is also important to evaluate the results of each step in the therapeutic process.

The current availability of high-tech diagnostic tools does not supplant the need for a urologist who is able to identify the salient facts in the history and findings on physical examination, as these are the bases for the correct management choice. The urologist must also be skilled in extracting the relevant results from technical or laboratory tests and in integrating these into the given management pathway.

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

Get My Free Ebook

Post a comment