Emergency Department / Clinical Decision Unit
Protocol for the investigation of adults with
suspected Renal Colic on the CDU
Patient details, including ED number
Date & time of arrival at ED
Date & time of arrival on CDU
Date & time of discharge
Next of Kin details
………………………
………………………
………………………
Inclusion criteria
History consistent with renal colic (e.g. loin pain radiating to groin) AND
Haematuria on urinalysis, AND
AAA excluded (clinically or by ED ultrasound)
Exclusion criteria Social circumstances prevent discharge within 24 hours
Heamodynamically unstable
Diabetic patient
Temperature > 38˚c
Pregnant or a Mother less than 3 months post partum
NB
Patients with atypical presentations or other abdominal pathology are not
suitable for this protocol.
Patients with suspected renal colic and exclusion criteria, should be referred
directly to the surgical/urology team.
If unable to send patient to CDU please document why (e.g. no space, patient too ill
etc…):
------------------------------------------------------------------------------------------------------------
Name
ED Number
Summary of Management Protocol
Presentation
Unilateral loin to groin pain
Dipstick positive haematuria
Management in ED
or CDU
Observations: temperature; pulse; blood pressure; respiratory rate; O2 sats; pain
score
Investigations:
 FBC, U&Es, glucose
 Blood cultures if core temperature > 38C
 Intravenous access
 MSU/urinalysis/pregnancy test
 Analgesia e.g. diclofenac 100mg PR (unless contraindicated)
 Anti-emetic (if required)
 KUB
Management in
CDU
Observations:
Pain score hourly
Temperature; pulse; blood pressure; respiratory rate; O2 sats 6 hourly

Measure urine output & strain urine (for stone collection)
Investigations:
 Arrange IVU immediately if between 09:00 – 21:00,
otherwise arrange for the following morning.
See IVU information (page6)!
Treatment:
Encourage fluid intake
Analgesia/anti-emetic as required
Timing of review: after 6 hours, clinical deterioration or with investigation
results.
Criteria for
discharge (after
any review)








Criteria for
urological referral
(at any time)











Symptomatically improved and a normal IVU
Pain controlled with oral analgesia
FBC and U&Es are normal
Diagnosis and treatment explained to patient
Social circumstances permit discharge
Instructed to return if increased pain, vomiting or fever
Letter to G.P.
Urology follow up arranged (next avail emergency slot in urology clinic) if
appropriate
Social circumstances prevent discharge within 24 hours
Unstable patient secondary to urological problem (exclude AAA)
Associated urinary tract infection
Abnormal IVU
Hyperglycaemia
Abnormal U&Es
Core Temperature > 38C
Frank haematuria
Unable to tolerate diet and fluids
Pain not adequately controlled
Potentially requires further urological investigation
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
2
Name
ED Number
Adult Modified Early Warning Score System
The scoring system has been designed to help both nursing staff and doctors to
identify patients who are at risk of becoming seriously ill. It should be calculated on
every adult patient after every set of observations have been done, or more frequently
if necessary.
SCORE
3
Heart Rate
Systolic BP
<70
Resp Rate per min
Urine output in last
4 hrs/mls
Central Nervous
System
Oxygen Saturation
Resp
Support/Oxygen
<80
2
1
0
1
2
3
<40
41-50
51-100
101-110
111-130
>130
71-80
81-100
101-179
180-199
200-220
>220
<8
8-11
12-20
21-25
26-30
>30
80-120
120-200
Pain
P
Unresponsive
U
>800
New
confusion
Awake
A
>95%
<85%
86-89%
90-94%
Bi-pap/CPAP
NIV
>10 litres
per min O2
Oxygen
therapy
Verbal
V
Each measurement is given a score from the table above. If the patient’s total score is
> 3, or 3 in any one category, or their condition is causing concern then the ED Middle
Grade should be asked to review the patient.
Pain assessment
0
2
4
6
8
10
________________________________________________________
no pain
worst pain imaginable
Ask the patient to rate their pain on the scale of 0-10, at Rest and on Movement.
When an analgesic drug is administered the patient must be reassessed 30 minutes
later to assure the patient is comfortable, pain score less than 4.
If the patient is prescribed analgesia regularly and their pain score is less than 4 it is
not necessary to reassess.
Analgesia given?
Y
yes
N
no
R
refused
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
3
Name
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
ED Number
4
Name
ED Number
History presenting complaint
Past Medical History
Drug History
Examination
Impression / Diagnosis
Plan:
1
2
3
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
5
Name
ED Number
IVU Information
An IVU will be performed between 09:00 and 21:00. Complete the request on EDIS.

The Administration of Intravenous Contrast Medium check-list MUST be completed by the
CDU/ED middle grade Dr prior to the patient having the KUB image. (LMP section falls within
IR(ME)R 2000 regs.)

 Documentation must accompany the patient to X-Ray
Contrast Medium Injection
 Explain to the patient that during the injection, it is normal to experience ‘hot flush’,
metallic taste in the mouth or nothing and ask them to inform you of any other
‘feelings’/symptoms.
Contrast Medium to be injected over 2 minutes, then flushed with saline
Creatinine – up to 100umol/L proceed with injection of 50 – 100mls Ultravist 300
100 – 150 umol/L proceed + hydration inject 50 – 100mls Ultravist 300
150 – 200 umol/L proceed + hydration inject 50 – 100mls Visipaque
Anything above 200 umol/L Contrast Medium must not be injected.
The patient must be closely observed by a nurse for 30 mins after the iv contrast media is
given to ensure that any delayed reaction can be treated immediately.

 ED X-Ray staff must be informed immediately the injection has been performed in order
to ensure availability of staff and x-ray room for the 15 min KUB.

 The patient must be escorted to ED X-ray.

A single film at 15 mins post injection will be taken, and the patient brought back to CDU.

In normal working hours the radiologist will endeavour to provide a report for this film, but
initial interpretation should be by the referrer with urology discussion if needed.
Outside normal working hours a member of the urology team should review the IVU.

If the IVU at 15 mins shows any obstruction, the patient should be referred to the Urology
team.

 Radiographer will inform CDU staff if delayed images are required.

 CDU staff to inform ED X-Ray of the location of patients if transferred to
another ward, in the event delayed images are required.

Complete post contrast monitor form.

In the event of adverse reaction, action / treatment given to be recorded.

Radiology to be informed of any adverse reaction.
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
6
Name
ED Number
Investigations Requests
The following investigations should be performed on all those with suspected renal
colic (sign when requested).
Investigation
Nurse signature
(if requested)
Time requested
Reason if not requested
FBC, U&E, glucose
IVU
MSU
Blood cultures (if
temp. >38˚c)
Investigation results
AAA Excluded?
Blood test results
Hb
WCC
Glucose
CLINICALLY
ULTRASOUND
Platelets
Na
K
Urea
Creatinine
IVU Result
Other investigations
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
7
Name
ED Number
POST ADMINISTRATION OF CONTRAST MEDIUM OBSERVATION FORM
The patient must not be left unattended for 30 minutes.
Nausea / vomiting
Yes / No
Sneezing
Yes / No

Urticaria
Yes / No

Bronchospasm
Yes / No

Laryngeal Oedema
Yes / No

Hypotension

Generalised anaphylactoid reaction

Contrast medium extraversation

Delayed skin reaction (may occur up to a week after administration of contrast agent).
Time direct observation ceased ………………………………………………………..
Radiology informed of any contrast reaction
Yes / No
Signature of observer ……………………………………………………………………
Printed name of observer ……………………………………………………………….
Any actions / treatments to be recorded
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
8
Name
Date and Time
ED Number
Comments / notes
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
Signature/Name
9
Name
Date and Time
ED Number
Comments / notes
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
Signature/Name
10
Name
ED Number
CLINICAL DECISION UNIT DISCHARGE SUMMARY
Renal Colic
Patient Name/
Addressograph
GP Details:
Name
Address
Address
Date of Birth
Dear Dr
Your patient was admitted to the Clinical Decision Unit at Huddersfield Royal Infirmary
with SUSPECTED RENAL COLIC, having presented with loin pain and microscopic
haematuria.
Your patient was discharged after fulfilling the discharge criteria below
❐ Symptomatically improved
❐ Pain Free
❐ Apyrexial
❐ Normal IVU
❐ FBC and U&Es are normal
❐ Social circumstances permit discharge.
❐ Instructed to return if increased pain, vomiting, fever.
ADDITIONAL COMMENTS
_____________________________________________________________________
_____________________________________________________________________
_______________________________________________________________
Your patient has been has been advised to contact yourself or the Emergency
Department at Huddersfield Royal Infirmary should there be any further problems.
Thank you
Signed______________
Name__________________
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
Date___________
11
Name
ED Number
Administration of intravenous contrast media for IVU
Patient
Name name
Address
Address
LMP_____________
Possibility of pregnancy Y/N
DOB
Hospital No
Patient signature________________
Action taken___________________
For the patient to complete:
Have you ever had an injection of contrast media before?
Did you have a reaction to it?
Yes/No
Not applicable/Yes/No
Do you have any allergies?
Yes/No
Specify_____________________________________________________
Do you suffer from asthma, eczema or hayfever?
Yes/No
Do you have any heart or kidney problems?
Yes/No
Do you have any other health problems?
Yes/No
Specify_____________________________________________________
Do you take metformin?
If yes, do not take your metformin for the next 48 hours.
Yes/No
I confirm that I have read the above and it is a correct record to the best of my
knowledge.
I have been given a full explanation of the procedure i.e. IVU.
I agree to having an IVU performed.
Patient’s signature___________________________________
Date_________
Doctor’s signature___________________________________
Date_________
iv contrast________________
Lot no.____________________
Exp. date__________________
Reaction___________________
iv cannula insertion record
Date:
Time:
Site:
Treatment__________________
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
12
Name
ED Number
Information for patients having an IVU
What is an IVU?
An IVU or intravenous urogram is an X ray examination of the kidneys, ureters (tubes
between the kidney and the bladder) and the bladder.
These structures do not show up well on an ordinary X ray.
With an injection of a special dye/contrast medium into your vein, the kidneys, ureters
and bladder show up much better.
Why do I need an IVU?
The doctor looking after you in the Emergency Department and Clinical Decision Unit
(CDU) thinks you may have a stone somewhere between your kidneys and your
bladder. Some stones can be seen on an ordinary X ray of your abdomen, but this
does not show if the stone is causing any problems with the drainage of your urine
from your kidney. An IVU can show us if there is any blockage/obstruction to the flow
of your urine from the kidney.
What does this test involve?
You will be asked a series of questions to make sure it is safe to give you the dye into
your veins. You will be asked to sign a form to agree to have the procedure.
You will have an X ray before you have any dye. The doctor will then give you the dye
through a cannula inserted into a vein in you arm or hand. 15 minutes after you have
the dye, you will be asked to pass water and then another X ray will be taken.
Depending on what this X ray looks like depends whether you will require further X
rays aver the next few hours.
The results of the IVU are usually available within a few hours. The doctors will need
the results of the test before they can decide what other treatment you require.
If your IVU is normal you should drink more fluid over the next few days to help flush
the dye out of your body.
If you take metformin, do not take it for the next 2 days.
What are the risks and complications of having the dye?
When the dye is injected into your vein you may feel a flush of heat around your body,
but this disappears within a minute or two. You may have a metallic taste in your
mouth, or you may feel like you have wet yourself. There is no need to worry about
these things.
Thousands of people have this injection every day in X ray departments without any
problems. Some people do have an allergic reaction to the dye. If you are allergic to
the dye you may develop a rash or have a mild asthma attack. Very rarely someone
may have a severe allergic reaction. If this occurs the radiographers and the staff in
the Emergency Department and the CDU are trained to treat these reactions.
If you have any allergies or have previously had a reaction to X ray dye, you MUST let
the staff looking after you know!
Clinical Decision Unit, Huddersfield Royal Infirmary
Suspected Renal Colic Protocol
13