Download Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

Paramedic Care:
Principles & Practice
Volume 3
Medical Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chapter 7
Urology and Nephrology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Topics
Anatomy and Physiology
General Mechanisms of Nontraumatic
Tissue Problems
General Pathophysiology, Assessment, and
Management
Renal and Urologic Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Introduction
The urinary system performs a number of
vital functions:
– Maintains blood volume and the proper balance
of water, electrolytes, and pH (acid-base
balance)
– Removes a variety of toxic wastes from the
blood
– Maintains arterial blood pressure
– Controls development of red blood cells
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
The Urinary
System
– Female
– Male
Urology and
Nephrology
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
The Urinary System
Click here to view an animation on urine.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
The Kidneys
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Hilum
Medulla
Pyramids
Papilla
Renal Pelvis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Nephrons
– Glomerulus
– Bowman’s
Capsule
– Proximal Tubule
– Loop of Henle
– Distal Tubule
– Collecting Duct
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Formation of Urine
– Glomerular Filtration
GFR
– Reabsorption and Secretion
Simple diffusion and osmosis
Facilitated diffusion
Active transport
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Tubular Handling of Water and Electrolytes
– Diuresis and Antidiuresis
Tubular Handling of Glucose and Urea
– BUN and Creatinine
Control of Arterial Blood Pressure
– The Renin-Angiotensin System
Control of Erythrocyte Production
– Erythropoietin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Anatomy and Physiology
Ureters
Urinary Bladder
Urethra
Testes
Epididymis and
Vas Deferens
Prostate Gland
Penis
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Mechanisms of
Nontraumatic Tissue Problems
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Mechanisms of
Nontraumatic Tissue Problems
Inflammatory or Immune-Mediated Disease
Infectious Disease
Physical Obstruction
Hemorrhage
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Pathophysiology,
Assessment, and Management
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
General Pathophysiology,
Assessment, and Management
Differentiating GI and Urologic Complaints
Pathophysiologic Basis of Pain
– Causes of Pain
– Types of Pain
Visceral pain
Referred pain
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment and Management
Scene Size-up
Initial Assessment
Focused History
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OPQRST History
Prior History of Similar Event
History of Nausea, Vomiting, and Weight Loss
Change in Bowel Habits and Stool
Last Oral Intake
Presence of Chest Pain
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment and Management
Physical Exam
– Appearance
Uncomfortable appearance
– Posture
Lying with knees drawn up
Relief with walking
– Level of Consciousness
Determine if changes are acute or chronic
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment and Management
Apparent State of Health
Skin Color
Examination of the Abdomen
– Inspection for Distention, Ecchymosis, or
Scarring
– Pain Associated with Percussion of Abdomen
– Palpation
Normal or ectopic pregnancy
Masses
Assessment Tools
Vital Signs
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Assessment and Management
Management
– Airway, Breathing, Circulation
– Pharmacologic Interventions
IV access and analgesics
– Nonpharmacological Interventions
Nothing by mouth (NPO)
Maintain position of comfort
Reassess mental status and vital signs frequently
– Transport Considerations
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal and Urologic
Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal and Urologic
Emergencies
Risk Factors
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Older Patients
History of Diabetes
History of Hypertension
Multiple Risk Factors
Renal and Urologic Emergencies
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Acute Renal Failure
Chronic Renal Failure
Renal Calculi
Urinary Tract Infection
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Sudden drop in urine output to less than
400-500 cc/day
– Oliguria
Pathophysiology
– Prerenal Acute Renal Failure
Dysfunction before the level of kidneys
Most common and most easily reversible
– Renal Acute Renal Failure
Dysfunction within the kidneys themselves
– Postrenal Acute Renal Failure
Dysfunction distal to the kidneys
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Assessment
– Focused History
Change in urine output
Swelling in face, hands, feet, or torso
Presence of heart palpitations or irregularity
Changes in mental function
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Physical
Assessment
– Altered
mental status
– Hypertension
– Tachycardia
– ECG
indicative of
hyperkalemia
– Pale, cool,
moist skin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Physical
Assessment
(cont.)
– Edema of face,
hands, or feet
– Abdominal findings
dependent on the
cause of ARF
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Acute Renal Failure
Management
– Airway, Breathing, Circulation
– IV Access
Protect fluid volume
– Positioning and Transport
Consider nephrotoxic medications
Eliminate or discontinue if unsure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Chronic Renal Failure
– Permanent loss of nephrons
– End-Stage Renal Failure (ESRF)
Pathophysiology
– Similar to Renal ARF
Microangiopathy, glomerular injury
Tubular cell injury
Insterstitial injury
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Impairment of Kidney Functions
– Maintenance of blood volume with proper
balance of water, electrolytes, and pH
Increased sodium, water, and potassium retention
– Retention of key compounds such as glucose
with excretion of wastes such as urea
Loss of glucose and buildup of urea within the blood
– Control of arterial blood pressure
Disruption of the renin-angiotensin loop resulting in
hypertension
– Regulation of erythrocyte development
Development of chronic anemia
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Assessment
– Differentiate chronic and acute problems
– Focused history and physical exam
Gastrointestinal complaints
Changes in mental status
Marked abnormalities during physical exam
Uremic frost
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Immediate Management
– Monitor and support ABCs
– Establish IV access
Regulate fluid volume
– Monitor vital signs and cardiac rhythm
– Expedite transport to an appropriate facility
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Long-Term
Management
– Hemodialysis
– Common
complications
Bleeding from the
needle puncture
site
Local infection
Narrowing or
closing of the
internal fistula
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Chronic Renal Failure
Long-Term
Management
– Chronic ambulatory
peritoneal dialysis
(CPAD)
Utilizes the
peritoneal
membrane
Avoids some of the
shifts in fluid and
electrolyte balance
– Complications
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal Calculi
Pathophysiology
– “Too much
insoluble stuff” and
“too concentrated”
urine accumulates
– Stone types:
Calcium salts
Struvite stones
Uric acid
Cystine
© SIU/Photo Researchers
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal Calculi
Assessment
– Focused History
Severe pain in one flank that increases in intensity and
migrates from the flank to the groin
Painful, frequent urination with visible hematuria
Prior history of calculi
– Physical Exam
Difficult due to patient discomfort
Tachycardia with pale, cool, and moist skin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Renal Calculi
Management
– Maintain ABCs
– Maintain position of comfort
– Establish IV access
Fluid bolus may promote stone movement and urine
formation and promote pain relief
– Consider medication administration
Use caution with narcotic analgesics if possible GI
origin
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Priapism
Painful and prolonged erection of the penis.
Priapism affects only the corpora cavernosa.
The corpora spongiosum remains flaccid.
The most common cause of nontraumatic
priapism is sickle cell disease.
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Priapism
Other causes of priapism include:
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Leukemia
Multiple myeloma
Tumors
Spinal cord injury
Spinal anesthesia
Carbon monoxide poisoning
Malaria
Black widow spider bites
Prescription and non-prescription drugs
Treatment
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Urinary Tract Infection
Pathophysiology
– Risk Factors
Increased risk in female or catheterized patients
Sexual activity
– Lower and Upper UTIs
Urethritis
Cystitis
Prostatitis
Pyelonephritis
Community-acquired vs. nosocomial infections
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Urinary Tract Infection
Assessment
– Focused History
Abdominal pain
Frequent, painful urination
A “burning sensation” associated with urination
Difficulty beginning and continuing to void
Strong or foul-smelling urine
Similar past episodes
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Urinary Tract Infection
Assessment
– Physical Exam
Restless, uncomfortable appearance
Presence of a fever
Vital signs vary with degree of pain
Management
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Maintain ABCs
Establish IV access
Consider analgesics
Transport to appropriate facility
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ
Summary
Anatomy and Physiology
General Mechanisms of Nontraumatic
Tissue Problems
General Pathophysiology, Assessment, and
Management
Renal and Urologic Emergencies
Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed.
© 2009 by Pearson Education, Inc. Upper Saddle River, NJ