Dialysis Emergencies (Dr. Gruber):
- Ask patient when last dialyzed
- Ask patient about their dry weight
- Ask patient if they still make urine
- What are the different types of access?
- Graft
- Can use after 3 weeks
- Need to avoid BP cuffs, circumferential bandages –> restrict flow –> thrombosis
- Catheters (tunneled or un-tunneled)
- High rate of thrombosis
- Fistula
- Increases pressure in walls of vein –> vein enlarges and walls thicken –> allows vein to take repeated sticks
- Requires 3-4 months before able to use; Longest functional use
- Graft
- Morbidity of ESRD:
- Cardiovascular disease: 50%
- If coding a renal patient, ask what is wrong with the heart?
- Take any complaints of chest pain very seriously (they can have more symptoms with less ischemic disease than other patients)
- Infection: 20%
- Neurological: 6%
- 4x mortality if:
- Receive <4hrs week of dialysis
- If start dialysis >60 y/o
- Cardiovascular disease: 50%
- What do I do with elevated troponins if their troponins are always elevated?
- Get serial troponins (usually >20% serial change is threshold)
- What do I do with acute volume overload in dialysis patients?
- MC etiology: missed HD, diet
- Ask about their dry weight and last dialysis session
- Treatment similar:
- IV Nitroglycerin
- IV Lasix (60-100mg) – even if they don’t make urine
- BiPAP
- Hemodialysis
- If patient is hypotensive, don’t forget to look for pericardial tamponade!
- Right atrial diastolic collapse- most specific sign
- Easy to miss on CXR with cardiomegaly
- 50% patients on dialysis have pericardial effusion (dialysis related or uremic related)
- If pericardial effusion and hypotensive:
- 1st step – IVF (increase venous return as these patients are preload dependent)
- Then, can do an ultrasound guided pericardiocentesis
- If patient is bradycardic, think about Hyperkalemia!
- K+ number does not correlate to EKG changes
- Often require 3 rounds of calcium gluconate to see EKG changes resolve
- Use half dose of insulin in ESRD patients (insulin is excreted by kidneys so stays around longer)
- Do not give albuterol as the first and only medication
- What do I need to remember for a septic ESRD patient?
- #1 source = catheters
- Broad spectrum antibiotics to cover MRSA and pseudomonas
- Give 250cc fluid bolus and re-evaluate
- Talk to renal about whether catheter needs to be pulled
- Why do patients become hypotensive during dialysis?
- Inadequate time for transcellular shifts
- May require longer or more frequent dialysis sessions instead
- Autonomic dysfunction
- It is an independent predictor of mortality
- What are the neurological complications in ESRD patients?
- CVA (2/2 poor protoplasm and HTN)
- More likely hemorrhagic 2/2 platelet and clotting dysfunction
- Intracranial bleed: 10x higher and 40% mortality
- Encephalopathy (2/2 uremia or HTN or dialysis disequilibrium syndrome)
- Seizures
- 1/2 your dose of Phenytoin since most ESRD patients have hypoalbuminemia leading to displacement of drug from serum proteins –> increase in volume of distribution –> same pharmacologic effect with lower total blood concentration (level that you check in the blood)
- Dialysis disequilibrium syndrome
- 2/2 rapid changes in body fluid composition and osmolality
- Usually when you start dialysis
- Sx: HA, malaise, N/V, cramps to AMS, seizure or coma
- Sx can resolve spontaneously over hours (as fluid/solutes redistribute)
- Tx: lower ICP with mannitol or hypertonic NS
- Vascular Access Problems
- AV Fistula Stenosis: from endothelial/fibromuscular hyperplasia
- Inflow Stenosis
- Weakened radial pulse
- High pitched bruit at site of stenosis
- Outflow Stenosis
- Bounding pulse distal to stenosis
- Loss of thrill
- Inflow Stenosis
- Thrombosis
- MCC: stenosis –> decreased blood flow/increased venous resistance
- Can occur after HD from low BP (venous stasis) and excessive compression of access site for hemostasis post dialysis
- Aneurysm/Pseudo-aneurysm:
- From excessive cannulation –> weakening of vessel wall
- Can present with pain or neurologic complaints (2/2 compression of nerves)
- Pseudo-aneurysm: pulsating extravascular hematoma
- Use ultrasound and obtain a Vascular consult
- Bleeding
- Why?
- Inherent anticoagulation 2/2 uremia and platelet dysfunction
- Also given heparin to prevent clotting in the dialysis circuit
- Stop with direct pressure/elevation and surgical
- 2 hand method: Dominant hand applying direct pressure to bleeding site/distal to the site while non-dominant hand applying pressure proximal to bleeding site
- Figure of 8 stitch
- Worst case scenario: tourniquet proximal to puncture site (but will cause thrombosis)
- Consider protamine sulfate (if within hours of dialysis to reverse heparin)
- Give slowly (can cause histamine reaction and anaphylaxis)
- Consider DDAVT (releases vWF)
- Do not give in hyponatremia, CHF or unstable angina
- Consider TXA
- Consider FFP/Cryoprecipitate
- Observe for 2 hours for rebleed or thrombosis
- Check thrill and listen for bruit prior to d/c
- Why?
- AV Fistula Stenosis: from endothelial/fibromuscular hyperplasia
Serving Deaf in Medical Settings (Kerrie Ellen):
- Watch Video
- “The single biggest problem with communication is the illusion that is has taken place.” -G.B. Shaw
- Deaf culture and their visual approach to the world may make them seem not with it, distracted, or spastic.
- Not all Deaf can read your lips. Can you read their lips? Are you sure?
- Written communication might work, but it might lead to misinformation and missed information.
- Be careful using VRI (Video Remote Interpreter, or the machine interpreter)- it doesn’t facilitate communication for everyone all the time.
- Using a family member as an interpreter is tricky since less than 10% of hearing family members can communicate effectively with the Deaf
- Basic Sign Language you can use while waiting for your interpreter
- To request interpreter during business hours at Jacobi, call ex. 5245 (talk to Maja)
Priapism (Dr. Ndukwe):
- For penile blocks, aspiration and phenylephrine injections…aim for 10 o’clock or 2 o’clock on dorsal aspect.
- Ventral approach risks hitting urethral and dorsal midline approach risks hitting penile vasculature
- Get a thorough history (if possible, obtain medication list)
- Do a thorough physical exam (e.g. lower leg weakness + priapism = spinal cord pathology)
- Give IM terbutaline +/- PO ephedrine from the get go (Anecdotally, Gruber said this has worked for many of his priapism cases)
Hands-on Defibrillation (Dr. Schramm):
- Reducing CPR interruptions = better short/long-term pt outcomes
- With every pause in CPR, coronary perfusion pressure rapidly drops
- Perfusion pressure is not quickly restored once CPR resumes (takes time to come back up)
- Good evidence that maintaining coronary perfusion pressures leads to improved likelihood of ROSC.
- No evidence yet that hands-on defibrillation (should minimize loss of
perfusion pressure) improves outcomes- That being said…research lags because there aren’t enough people willing to perform it…because we’re afraid of getting electrocuted
- Where does a defibrillation shock go?
- Voltage path: from anterior/superior pad –> lateral/posterior pad
- Nearly all voltage passes along the direct route, except for a small amount of voltage leakage
- Defibrillation shocks do not travel to the patient’s feet, stretcher, air around the stretcher, or into your hands.
- How dangerous is hands on-defibrillation?
- No evidence of any provider ever going into V-fib after an accidental shock.
- Much anecdotal data suggests safe using regular exam gloves.
- However…
- Insensible levels of voltage exposure are theoretically cardio-active (dangerous)
- Regular exam gloves probably break down with repeated shocks and may not provide sufficient protection.
- Rubber class 1/0 high-voltage, electrical gloves protect against direct voltages vastly higher than experienced by a CPR provider.
- Proposition:
- We do potentially dangerous procedures all the time (IV/central line placement, code panda, chest tubes on pts receiving CPR)
- Each of these is more likely to injure the provider, than hands-on-defib.
- We probably should not change our practice right away, at least not at an institutional level.
- Don’t be needlessly scared of the defibrillator!
- Attempt to minimize CPR interruptions!
- We do potentially dangerous procedures all the time (IV/central line placement, code panda, chest tubes on pts receiving CPR)