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EM > WK 7- Renal and Haematological Emergencies > Flashcards

WK 7- Renal and Haematological Emergencies Flashcards

1
Q

What are the functions of the kidneys

A
  • Excretion of waste products
  • Acid base homeostasis
  • Osomolality homeostasis
  • BP regulation→ ie. Renin angiotensin system
  • Hormone synthesis/metabolism
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2
Q

What are some causes of pre-renal failure

A
  • Hypovolemia
  • Hypotension→ Cardiogenic shock, sepsis, anaphylaxis
  • Reduced effective circulating volume→ Generalised oedema secondary to cardiac failure, liver failure, nephrotic syndrome
  • Renal hypoperfusion→ Renal artery stenosis, hepatorenal syndrome
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3
Q

What does pre-renal failure mean

A

failure resulting from anything that impairs blood flow to kidneys

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4
Q

What are some complications of renal failure

A

CNS→ Altered LOC, confusion, seizures
CVS→ Dysrhythmias, fluid overload
GIT→ Stress ulceration, ileus
Haematological→ Anaemia, platelet dysfunction
Metabolic→ Hyperkalemia, hypocalcemia, metabolic acidosis
Immunological→ Infection, poor wound healing

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5
Q

What are some renal causes of renal failure

A

Vessels
→Large: renal artery thrombosis/embolism/dissection, renal vein thrombosis
→Small: vasculitis, malignant hypertension, thrombotic microangiopathy (HUS/TTP)
-Glomeruli: Glomerulonephritis
-Renal tubules→ Acute tubular necrosis- can be ischemic or Cytotoxic – pigments, drugs
-Renal interstitial tissue→ Acute tubulointerstitial nephritis

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6
Q

What are some causes of post-renal failure

A

Internal obstruction→ Stone, clot, casts, crystals
External–> compression→Prostatomegaly, tumour, haematoma
→ can be relieved by indwelling urinary catheter

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7
Q

How is acute renal failure managed

A

Treat reversible causes

  • Pre-renal→ correct hypovolemia, hypotension, anaemia (give blood transfusion)
  • Post-renal→ IDC, SPC or nephrostomy tube for higher obstruction
  • Avoid secondary insults→ avoid non-steroidals, amino glycosides→ these worsen renal failure
  • Maintain urine output
  • Treat complications→Hyperkalemia Tx, Renal Replacement Therapy (haemodialysis for chronic renal failure patients)→ complications mainly occur chronic renal failure
  • Specific treatment for underlying cause
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8
Q

What does hyperkalemia cause? How can it be fatal?

A

-Causes hyperpolarisation/repolarisation of the cell membrane leading to difficulty in initiating an action potential-> causes dysrhythmias (potentially life threatening), muscle weakness

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9
Q

What ECG changes are seen in a person with hyperkalemia

A

Peaked T wave, broad QRS, shortened PR, flat/or no P wave

-over time will become sinusoidal

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10
Q

How is hyperkalemia treated

A

-Stabilise cardiac membranes→ calcium gluconate 10ml→ give calcium only to pt with abnormal ECG or K+ greater than 7.5
-Shift K into cells→
-Nebulised salbutamol 20mg→ shifts K intracellularly
-IV actrapid (insulin)
-IV NaHCO3 100mmol
-Enhance elimination of potassium–>
PO/PR resonium 50g→ binds K in gut and creates osmotic gradient that pulls K out of the gut and excretes
-IV frusemide diuresis→ useful in fluid overload in pt
-Renal replacement therapy- Dialysis

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11
Q

What conditions lead to chronic renal failure

A

Diabetes, reflux neuropathy, -Glomerulonephritis, Polycystic kidneys, Renovascular, Predominantly renal causes

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12
Q

How is chronic renal failure managed

A
  • Dialysis→ Haemo vs Peritoneal (can do at home→ flood the peritoneal with diasolate-> body will slowly calibrate on its own)
  • Protein + fluid restriction
  • BP control→ tend to be hypertensive, so are on multiple anti-hypertensives
  • Supplements
  • Ca, vit D, Fe, PO4 binders, multivitamins
  • Erythropoietin→ stimulates RBC formation
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13
Q

What is haemostasis

A

-a constant process of clot formation and clot lysis→ so there is no abnormal thrombosis

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14
Q

What are the 3 processes of haemostasis

A

-Vasoconstriction, platelet plug formation and coagulation

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15
Q

What 3 factors contribute to abnormal bleeding

A

→vessel injury–> severing the vessel can cause haemorrhage (cannot be repaired via platelet plug)
→ platelets; thrombocytopenia, platelet dysfunction (ie. Aspirin/clopidogrel)
→ coagulation cascade; coagulopathy

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16
Q

What are the two ways in which a person can get coagulopathy

A

Congenital or acquired

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17
Q

How can coagulopathy be congenital

A

ie. inherited syndromes like haemophillia

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18
Q

How can coagulopathy be acquired

A

→Inadequate synthesis; Liver disease, vit K deficiency
→Coagulation inhibition; Antibodies, drugs (ie. Warfarin, novel oral anticoagulants)
→Coagulation factor consumption;
Disseminated intravascular coagulation, snakebite

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19
Q

How is major bleeding managed

A

Resuscitation→ DRABCD
-Early source control→ stopping the bleeding
→ Physcial measures: pressure (ie. Lower limb bleed-pressure on femoral artery), elevation, splinting- helps tamponade the bleeding and alleviates pain
→ Surgical haemostasis: damage control surgery → controlling bleeding and correcting haemodynamics initially
→ Specific medical treatment: eg- upper GI bleed= PPI+ octreotide, antivenom for snakebite (Binds to venom and stops progression of coagulopathy)

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20
Q

What is tranexamic acid

A

anti-fibrinolytic derivate of lysine that interferes with the normal fibrinolysis process and competitively inhibits activation of plasminogen through reversible interactions with lysine-binding sites on the enzyme

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21
Q

How does saline make coagulopathy worse in a major trauma

A
  • dilutes clotting factors- prolonging haemorrhage

- has no oxygen carrying capacity-> further decreases perfusion to tissues

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22
Q

What is the ratio of RBC:FFP:Plts used in major trauma

A

1:1:1

23
Q

How much blood is in an;

  • adult
  • child
  • infant
A

Adult 70ml/kg = approx 5L
Child 80ml/kg
Infant 90ml/kg

24
Q

If the pH is below 7, what will not clot effectively

-what does this mean for management

A
  • Platelets do not clot below a pH of 7

- have to control acidosis before giving transfusion

25
Q

What factors do not work in low temperatures

A
  • Clotting factors

- need to correct hypothermia before transfusion

26
Q

What are the 2 definitions used for a massive transfusion

A

→ Replacement of > ½ blood volume (5units RBC) within 4 hrs
OR
→Replacement of full blood volume (10units RBC) within 24hrs

27
Q

What is serum

A

-is essentially plasma (has proteins, water, hormones) just without clotting factors

28
Q

What is plasma

A

contains proteins, water and other solutes (like clotting factors and hormones)

29
Q

What complications can arise from a massive transfusion

A
  • Hypothermia→ if you don’t warm products, can become hypo
  • Acidosis
  • Haemodilution→ if blood products have lower cellular content
  • Consumption of clotting factors + platelets
  • Use of fractionated blood products
  • Disseminated intravascular coagulation
  • Coagulopathy + microvascular bleeding
30
Q

The ureters travel from the kidney toward the bladder in close association with what muscle?

A

Psoas major

31
Q

How long are the ureters (approx)?

A

25-30 cm

32
Q

What is the narrowest part of the urogenital tract? (i.e. where renal stones are most likely to get stuck)

A
  • Ureteropelvic Junction (UPJ)→ anatomical location where the inside of the kidney connects to the ureter→ occlusion of stone causes colic pain
  • as the ureter enters the pelvis and crosses over the common iliac artery bifurcation
  • at the vesicoureteric junction (VUJ) as the ureter obliquely enters the bladder wall
33
Q

The hilar of each kidney is near the transpyloric plane. At what level is the transpyloric plane?

A

-L1 vertebral body→ cuts halfway through the pylorus

34
Q

Where would you expect to feel pain from the kidney

A

Loin to groin→ begins below ribs and radiates towards the groin

35
Q

Where would you expect to feel pain from the ureter

A

flank pain on affected side/loin to groin

36
Q

Where would you expect to feel pain from the urethra

A

suprapubic regon

37
Q

Where would you expect to feel pain from the bladder

A

suprapubic region

38
Q

Why can urogenic pain be either colicky or constant

A
  • these structures are hollow viscous organs that have peristaltic waves passing through→ if a stone is moving, it will causes colicky pain due to the peristaltic waves
  • constant pain is caused by inflammation→ pyelonephritis
39
Q

What are some complications of catheterisation

A

-urinary tract infection, bladder spasms, blood/debris in the catheter, damage to the urethra, formation of scar tissue, bladder stones, injury to bladder or rectum

40
Q

What is the role of the kidney in the renin-angiotensin system?

A

releases renin from juxtagolmerular cells→ renin converts angiotensinogen to angiotensin 1 so that it can eventually can be converted to angiotensin 2→ angiotensin 2 acts to increase BP through vasoconstriction, release of aldosterone, reabsorption of Na+, ADH release

41
Q

What is the action of aldosterone

A
  • Aldosterone is a type of steroid hormone that acts primarily in renal collecting ducts to stimulate reabsorption of Na+ as well as secretion of K+ and H+→ increases BP
42
Q

What blood group is a universal donor

A

O- has no surface antigens

43
Q

What blood group is a universal recipient

A

AB+ has no preformed antibodies

44
Q

In trauma, what three factors contribute to coagulopathy?

A
  • Hypothermia, coagulopathy/consumption, acidosis
  • these factors contribute to acute coagulopathy of trauma/shock→ hypothermia causes decreased clotting factor activity, acidosis prevents platelet function, coagulopathy can cause further bleeding and acidosis
45
Q

What is the MOA of frusemide

A

inhibit basolateral Na+/K+/2Cl-pumps in the ascending limb of the loop of Henle

  • results in marked and rapid decrease in Na+ an Cl- reabsorption causing increased uresis and reduced BP
  • avoid in those with low blood volume/dehydration
46
Q

Which of the following is true regarding the hilum of the right kidney

  1. it is at the level of the lower border of L1
  2. it is deep to the transpyloric plane
  3. it is at a higher level than the hilum of the left kidney
  4. it moves with respiration
A

1, 2 and 4

47
Q

Where would the pain from a renal calculus lodged at the ureto-vesical junction usually be felt

  1. Loin
  2. groin
  3. scrotum
  4. radiating from loin to groin
A

Groin

  • stone higher up will have to move through the ureter-> causes visceral pain
  • when stone becomes stuck it becomes painful around the groin
  • those that are stuck in the bladder neck cause pain to radiate to the penis/scrotum
48
Q

What kind of pain (visceral or somatic) does renal colic cause

A

visceral

49
Q

Which of the following is typical of renal colic

  1. patient can’t get comfortable
  2. sharp pain, worse with movement
  3. peritonism
  4. fever
A

pt can’t get comfortable

-peritonism indicates fluid/blood in peritoneum which is made worse by pressure

50
Q

Which of the following would cause pre-renal failure

  1. glomerulonephritis
  2. acute tubular necorsis
  3. renal artery stenosis
  4. prostatomegaly
A

renal artery stenosis

51
Q

Which of the following would be most likely to cause post-renal failure

  1. glomerulonephritis
  2. renal calculi
  3. cervical cancer
  4. bladder calculus
A

cervical cancer–> invades bladder neck

52
Q

Which of the following is a consequence of chronic renal failure

  1. tetany
  2. bleeding tendency
  3. clotting factor deficiency
  4. dehydration
A

tetany and bleeding tendency

  • tetany due to electrolyte imbalances (hypocalemia)
  • bleeding is due to; coag factors not working (acidotic),
53
Q

Which of the following applies to group A pos blood

  1. group A antigen and group a antibody
  2. group A antigen and group B antibody
  3. group B antigen and group B antibody
A

A antigen and B antibody

54
Q

Which of the following is universal donor

  1. O pos
  2. O neg
  3. AB pos
A

O neg

EM (11 decks)

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