0071643192.pdf

RENAL AND GENITOURINARY

EMERGENCIES

■ Bleeding
■ Multifactorial: Decreased platelet function, altered von Willebrand factor
■ May include subdural hematomas, GI bleeding
■ Encephalopathy
■ May include mental status changes, hiccups, asterixis (hand flapping
with dorsiflexion), and myoclonic twitching
■ Hyperkalemia (see Chapter 14)
■ Metabolic acidosis
■ Immunosuppression
■ Peripheral neuropathy
■ Sensorimotor

TREATMENT

■ If patient is not ESRD, look for and treat reversible causes of renal failure
(“acute on chronic renal failure”).
■ Usual management of HTN, pulmonary edema, hyperkalemia
■ Dialysis
■ Renal transplantation
■ Acute bleeding:
■ DDAVP: First-line, stimulates release of vWF from endothelial cells
■ Cryoprecipitate: Contains factors I (fibrinogen), II (fibronectin), VIII,
XIII, and vWF
■ Conjugated estrogens: Increases platelet reactivity and decreases nitric
oxide generation
■ Transfusion of PRBCs: To hematocrit of 30%

A 45-year-old female with ESRD presents to the ED complaining of

shortness of breath. Her last dialysis was 1 day prior via a recently place

right arm AV fistula. She does receive erythropoietin replacement therapy.

As part of your physical examination, you temporarily occlude her dialysis

access site and observe a drop in her heart rate. What diagnosis does this finding

support?

The drop in heart rate with occlusion of the dialysis access site is termed Branham

sign, which indicates a high-output heart failure from excess flow through the AV

fistula. The diagnosis can be confirmed with Doppler ultrasound.

DIALYSIS-RELATED EMERGENCIES

Dialysis can be in the form of hemodialysis (HD) where an artificial mem-
brane filters solute and fluids, or peritoneal dialysis (PD) where the peritoneal
membrane serves as the dialysis membrane. HD allows for faster exchange of
solute and fluids.

Indications for Emergent Dialysis

Indications for emergent dialysis are listed in Table 18.5.

Indications for

emergent dialysis—

AEIOU

Acidosis

Electrolyte (K >6.5,

BUN >100, Creatinine

>10)

Ingestions

Overload (fluid)

Uremia