Renal medical emergencies Flashcards
Name 5 symptoms of hyperkalaemia.
- Muscle weakness
- Fatigue
- Palpitations
- Nausea
- Muscle cramps
What is the first line investigation once hyperkalaemia is confirmed?
12 Lead ECG
In a patient with moderate or severe hyperkalaemia presenting with ECG changes what is the first line medical management?
Acute severe hyperkalaemia (plasma-potassium concentration above 6.5 mmol/litre or in the presence of ECG changes) calls for urgent treatment with calcium gluconate 10% by slow intravenous injection, titrated and adjusted to ECG improvement, to temporarily protect against myocardial excitability.
Following calcium gluconate injcetion what is the next medical management in moderate or severe hyperkalaemia presenting with ECG changes?
An intravenous injection of soluble insulin (5–10 units) with 50 mL glucose 50% given over 5-15 minutes, reduces serum-potassium concentration; this is repeated if necessary or a continuous infusion instituted.
What is the additional medical management that can be attempted alongside insulin+glucose?
Salbutamol [unlicensed indication], by nebulisation or slow intravenous injection may also reduce plasma-potassium concentration; it should be used with caution in patients with cardiovascular disease.
What is the first line medical management in patients with mild hyperkalaemia?
Calcium resonium
Give 6 signs and symptoms of pulmonary oedema?
Symptoms
- Shortness of breath
- Respiratory distress
- Production of pink frothy sputum (haemoptysis)
Signs
- Pallor
- Tachypnoea
- Decreased oxygen saturations
- Raised jugular venous pressure (JVP)
- Peripheral oedema
What approach should you take when treating someone with hyperkalaemia?
An ABCDE approach
If a patient is found to be breathless but with a patent airway, what two oxygen options should be considered?
Oxygen
- Sit patient upright if possible
- Administer high flow oxygen (15L/min) via a non-rebreather mask
Non-invasive ventilation
Continous positive airway pressure (CPAP) should be considered for patients who do not improve after supplemental oxygen and intravenous diuretics (see below). Commencing CPAP is a skill beyond the scope of most junior doctors and should always involve more senior doctors.
What are the two key investigations in pulmonary oedema?
- CXR
- ABG
What is the main intervention in pulmonary oedema?
40 – 80mg IV boluses / IV infusion furosemide (titrated to response)
Give 5 signs and symptoms of metabolic acidosis
- Long and deep breaths
- Fast heartbeat
- Headache and/or confusion
- Weakness
- Feeling very tired
- Vomiting and/or feeling sick to your stomach (nausea)
- Loss of appetite
What is the management of metabolic acidosis?
HCO3- can be administered intravenously to raise the serum HCO3- level adequately to increase the pH to greater than 7.20. Further correction depends on the individual situation and may not be indicated if the underlying process is treatable or the patient is asymptomatic.
Name 3 physiological modalities for maintaing [H] at 40nEq/L
Under normal conditions, acids and, to a lesser extent, bases are being added constantly to the extracellular fluid compartment, and for the body to maintain a physiologic [H+] of 40 nEq/L, the following three processes must take place:
- Buffering by extracellular and intracellular buffers
- Alveolar ventilation, which controls PaCO2
- Renal H+ excretion, which controls plasma HCO3-
What are the 3 key pieces of information that doctors try to find out when investigating uraemia?
- To differentiate acute from chronic uraemia.
- To document the degree of renal impairment and obtain baseline values so that the response to treatment can be monitored. This is accomplished by measurement of serum urea and creatinine.
- To establish whether AKI is prerenal, renal or postrenal, and to determine the underlying cause so that specific treatment (e.g. intensive immunosuppression in Wegener’s granulomatosis) may be instituted as early as possible and thus prevent progression to irreversible renal failure.
Give 5 symptoms of uraemia
- extreme tiredness or fatigue
- cramping in your legs
- little or no appetite
- headache
- nausea
- vomiting
- trouble concentrating
What is the management of uraemia?
Dialysis
Give the indications for emergency dialysis
There are three main indications for emergency dialysis in acute renal failure:
- severe hyperkalaemia (K+ > 7mmol/L) which is resistant to medical therapy
- pulmonary oedema refractory to medical therapy
- worsening severe metabolic acidosis (pH < 7.2 or base excess < -10)
Other possible indications include:
- uraemic pericarditis
- uraemic encephalopathy
What drugs should be stopped to limit the likelihood of developing renal complications?
Stop the DAMN drugs
- D- Diuretics and digoxin
- A- ACEIs and ARBs
- M- Methotrexate and metformin
- NSAIDs
