›High risk presentation
›Hemodynamic instability
›Escalate to resuscitation bay for SBP < 90 mmHg
›Escalate to resuscitation bay for altered mental status
›Ongoing brisk bleeding
›Activate massive transfusion protocol for suspected hemorrhagic shock
›Early urology consult for suspected clot retention with obstruction
›Urinary obstruction
›If inability to void with suprapubic pain, treat as clot retention until proven otherwise
›If anuria with flank pain, urgent imaging for obstruction
›Initial monitoring
›Continuous cardiac monitoring
›Telemetry for active bleeding or anemia
›Frequent blood pressure checks
›Arterial line if rapidly changing hemodynamics
›Strict intake and output
›Urine output target 0.5 ml/kg/hour
›Access and resuscitation
›Two large bore IV lines
›If difficult access, intraosseous access
›Balanced crystalloid only for temporizing hypotension
›Transition to blood products for suspected hemorrhagic shock
›Transfusion thresholds
›If active bleeding, transfuse based on physiology and ongoing loss rather than a single hemoglobin value
›If coronary disease or symptoms, consider higher hemoglobin threshold
Time critical causes and triggers
›Cannot miss etiologies
›Malignancy
›Bladder cancer
›Upper tract urothelial carcinoma
›Renal cell carcinoma
›Vascular catastrophe
›Abdominal aortic aneurysm with aortoenteric fistula
›Renal infarction
›Severe infection
›Urosepsis with hematuria
›Emphysematous cystitis
›Obstruction complications
›Bilateral obstruction
›Solitary kidney obstruction
›Escalation triggers
›If fever with rigors, early antibiotics after cultures
›If hypotension, sepsis bundle
›If severe flank pain, urgent CT for stone with obstruction
›If infected obstruction, emergent decompression pathway
›If painless gross hematuria, malignancy workup pathway
›Arrange cystoscopy and upper tract imaging