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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. Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company • www.jblearning.com 1 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. Copyright © 2013 by Jones & Bartlett Learning, LLC, an Ascend Learning Company • www.jblearning.com 2