Download Chapter 21 Genitourinary and Renal Emergencies Case PowerPoint

Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
Chapter 21
Genitourinary and Renal Emergencies
Case PowerPoint Answers
1. What is the purpose of dialysis?
Answer: Renal dialysis is a process that filters toxic wastes from the blood, removing
excess fluid, and restoring the normal balance of electrolytes. It may be used to treat
acute conditions or, in the case of most patients, used to treat chronic renal failure.
2. What are the two types of dialysis?
Answer: Two types of dialysis include peritoneal dialysis and hemodialysis. In peritoneal
dialysis large amounts of specially formulated dialysis fluid are infused into the
peritoneal cavity. Fluid remains in the peritoneum for 1 to 2 hours allowing diffusion of
water and wastes into the dialysis fluid to be removed later. In hemodialysis, the patient's
blood circulates through a dialysis machine that functions in much the same way as the
kidney. Most patients undergoing hemodialysis have a shunt to be connected to the
dialysis machine for removal of unfiltered blood and return of filtered blood.
3. What conditions is this patient most likely experiencing?
Answer: Considering the ECG, we would expect hyperkalemia as a common electrolyte
imbalance observed in patients who miss their dialysis appointment. There are two other
conditions we must always consider in the patient who misses their dialysis appointment:
hypervolemia (fluid volume overload) and metabolic acidosis. Because patients in renal
failure cannot create urine, hypervolemia can occur as evidenced in our patient by her
signs of JVD, HTN, and extremity edema. Furthermore, because waste products build up
in the bloodstream we should also consider metabolic acidosis as an additional condition
in this patient.
4. What special concerns should you have regarding the patient’s condition?
Answer: There are several concerns with this patient. The presence of peaked T-waves
and suspected hyperkalemia puts the patient at risk for a life-threatening arrhythmia such
as V-Tach or V-Fib. The coarse crackles, tachypnea, decreasing oxygen saturation, JVD,
and extremity edema indicates that hypervolemia has caused left- and right-sided heart
failure. The patient is at risk for respiratory failure related to the pulmonary edema.
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Nancy Caroline’s Emergency Care in the Streets, Seventh Edition
Chapter 21: Genitourinary and Renal Emergencies
5. What types of shunts are used for patients who require dialysis?
Answer: Patients who undergo peritoneal dialysis have an external shunt that is
surgically placed into the peritoneal space. This allows the specially formulated dialysis
fluid (dialysate) to be delivered into the peritoneal space for exchange of electrolytes,
water, and waste products. Patients who undergo hemodialysis have an internal shunt that
is usually surgically implanted in their forearm or upper arm. This shunt connects an
artery and a vein together and therefore is often referred to as an arteriovenous (AV)
fistula. The AV fistula connected to the dialysis machine to allow blood to flow from the
body into the dialysis machine and back to the body.
6. Why should you not take a blood pressure in the arm that has a shunt?
Answer: Taking a blood pressure in the arm that has an AV fistula can damage the
special internal shunt. Dialysis patients rely on these shunts to function three times a
week until a kidney transplant is available. Taking a blood pressure in a shunt arm can
result in bleeding if a site has recently been accessed for dialysis.
7. What medications and interventions are indicated for this patient in the prehospital
setting?
Answer: We should consider this patient's most immediate diagnosis as pulmonary
edema secondary to fluid volume overload (hypervolemia). Although secondary
considerations such as hyperkalemia and metabolic acidosis warrant consideration, most
of the patient's serious signs and symptoms focus the differential diagnosis toward
pulmonary edema. Furthermore, treatment of hyperkalemia and metabolic acidosis
without the presence of lab values will be protocol dependant, but usually warrant no
treatment unless the patient is in the periarrest or arrest state. Focusing on the lifethreatening issue of pulmonary edema and associated respiratory distress, we would
consider the following: application of continuous positive airway pressure (CPAP);
administration of nitroglycerin, sublingual or intravenous NTG (preferred) titrated to
effect or until blood pressure no longer allows; waveform capnography monitoring to
reassess interventions; frequent 12-lead or 15-lead ECG monitoring.
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