Pyelonephritis

Pyelonephritis refers to a upper urinary tract infection, versus "cystitis" seen in the lower urinary tract. The most common organism is E. Coli, followed by Staph. saprophyticus.

Si/Sx

  • flank pain/CVA tenderness
  • nausea, vomiting
  • fever (> 38C)
  • frequency, dysuria
  • hematuria
  • pyuria

Dx

Urinalysis (“UA”) signs indicative of pyelonephritis include:

  • many WBC
  • nitrite + (nitrite indicates organisms able to reduce nitrate to nitrite, and does not include certain organisms such as enterococci)
  • esterase +
  • white cell casts: rare, indicate a renal source for pyuria
  • *note: the presence of epithelial cells indicates that the specimen was contaminated by contents outside the urinary tract. Epithelial cells are not found in the urinary tract.

A pelvic exam should be completed, as pelvic inflammatory disease is often confused with pyelonephritis. A pregnancy test should also be completed if LMP is unknown. Urine culture is also indicated, as resistance to empiric therapy may have serious sequelae.

Sequelae

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Ischemia

Signs of ischemia include "QRST-T"

 

Abnormal Q waves:

-  defined as > 0.04 seconds (1 small box) and greater than 1/3 the height of the R wave

- are normal in AVR, III?

 

T wave

- T wave inversion (TWI) is normal in lead III, AVR, V1

 

Coumadin

Mechanism

Prevents the liver synthesis of vitamin K dependent factors (2, 7, 9, 10)

Monitor

Coumadin (Warfarin) is monitored by PT, "WEPT"

Uses

Anticoagulation for: 

  1. post myocardial infarction
  2. mechanical heart valves
  3. thrombosis prevention in atrial fibrillation
  4. post PE/DVT

Heparin - Low Molecular Weight

Mechanism

Fractionated heparin that binds more specifically to factor X, LMWH has a better safety profile and does not require monitoring

Uses

  1. Myocardial infarct / Unstable angina
  2. Deep venous thrombosis / Pulmonary Embolus

Reversal

Also by protamine sulfate 

Heparin

Mechanism

Binds antithrombin III, inactivates clotting factors IX, X, and XII.  Heparin will prevent new clots from forming, but does not lyse existing clots.

 

Monitoring

PTT is used to monitor heparin, adequate dosing is roughly 1.5 to 2 times normal 

 

Reversal

Protamine Sulfate 

Digoxin

Mechanism

Disrupts sodium-potasium ATP-ase in cardiac myocardium, resulting in

  1. Negative chronotropy
  2. Positive inotropy

Uses

  1. Rate control in atrial fibrillation 
  2. To increase inotropy in LV dysfunction

Side Effects

  1. Overdose 

Adenosine

Mechanism

Causes AV nodal conduction block, short half-life (10 seconds)

Indications

  1. Diagnosis of supraventricular tachycardias 

 

Class IV Antidysrhythmics

Mechanism

Blockade of slow calcium channels

Examples

  • Verapamil, Diltiazem
    • primarily affect heart, "give your heart VD"
  • Nifedipine
    • primarily affect vessels

Primary Uses

  1. Dilt and verapamil:
    1. to control ventricle in rapid a-fib (like Class II)
    2. to control ventricle in SVT

Class III Antidysrhythmics

Mechanism

Sodium channel activation and potassium channel blockade

Examples

Amiodarone, bretylium, sotalol, ibutilide

Primary Uses

  1. Ibutilide: to break new onset a-fib

Class IC Antidysrhythmics

Mechanism

Large blockade sodium channel

Prolong repolarization and action potential duration

Examples

Propafenone, flecainide, encainide

Primary Uses