Medical Emergencies for Paramedics PDF

Medical Emergencies for Paramedics Code: PAR 341 Dr. Mohammad Alshloul 1  Module 1: Emergencies of Genitourinary and Renal System Disorders Objectives Define terms Genitourinary and Renal System Disorders. Label a diagram of t...

Medical Emergencies for Paramedics Code: PAR 341 Dr. Mohammad Alshloul 1  Module 1: Emergencies of Genitourinary and Renal System Disorders Objectives Define terms Genitourinary and Renal System Disorders. Label a diagram of the urinary system. Distinguish between acute and chronic renal failure. Outline the pathophysiology of renal failure. Identify the signs and symptoms of renal failure. Describe the process of hemodialysis and peritoneal dialysis. List signs and symptoms of emergency conditions associated with dialysis. Objectives Describe the pathophysiology, signs and symptoms, assessment, and pre-hospital management of a patient with urinary retention, urinary tract infection, pyelonephritis, urinary calculus, epididymitis, benign prostatic hypertrophy, and testicular torsion. Outline the physical examination of patients with genitourinary disorders. Discuss the general pre-hospital management of a patient with a genitourinary disorder.  Renal Diseases Kidneys: two bean shaped organs. They lie on the posterior abdominal wall behind the peritoneum t.jo The basic functional unit of the kidney is the I nephron. Millions of nephrons are inside each kidney. The roles of the nephron are to filter blood, remove waste products, and produce urine. Damage to the nephrons results in renal (kidney) disease. Components of Urinary System 1. Two Kidneys. 2. Two Ureters. 3. One Urinary Bladder. 4. One Urethra. Nephrons Kidney Nephron Nephron tubule  functions of kidney The mule monic Gametbed acid in memory of kidneys tunch A maintaining acid base balance w 1 water E balance Electrolyte balance Toxin removal B blood pressure E making control ERY Thoro poet In D vitmead metabolism  Renal Diseases The causes of renal failure can be classified as prerenal, intrarenal, and postrenal Mm 41 Prerenal disease is characterized by inadequate blood flow (perfusion) to the kidneys as a consequence of renal hypoperfusion in relation to events “outside” the kidney. WING 191 Intrarenal disease (intrinsic disease) refers to disease or damage within the kidney 1410 to V1 MTI M Postrenal disease refers to disease that blocks the system that collects urine. Classification depends on duration of renal failure and reversibility potential acute Reversable IS lil see it Chronis I  Assessment Findings and Symptoms of Renal Failure Acute Renal Failure ARF AKI Chronic Renal Failure End-Stage Renal Disease satia t son ▪ Reduced or no urinary output ▪ Headache ▪ Confusion ws styiriiaosyy ▪ wwwoutput Was isurinary Excessive at night ▪ Weakness ▪ Altered level of ▪ Lower extremity swelling ▪ Anorexia consciousness PE11.11.1 ▪ Anorexia ▪ Vomiting ▪ Shortness of breath s ▪ Altered mental status ▪ Increased urination ▪ Chest pain ▪ Metallic taste in mouth ▪ Rust-colored or brown ▪ Bone pain ▪ Tremors or seizures urine ▪ Pruritus ▪ Easy bruising or prolonged ▪ Increased thirst ▪ Nausea, vomiting, & diarrhea bleeding ▪ Hypertension ▪ Bruising ▪ Flank pain ▪ Pruritus ▪ Muscle twitching, tremors, ▪ Tinnitus g it electrolytes seizures ▪ Hypertension ▪ Hallucinations ▪ Abdominal pain or discomfort Renal Diseases n 985.91 Acute Kidney Injury (AKI) Life-threatening Occurs when kidneys cannot excrete the daily load of toxins in the urine Patients divided into two groups: Oliguric – excrete less than 500 mL/d Nonoliguric – excrete greater than 500 mL/day Mortality rate of hospitalized patients is 62%, but may be reversible if caught early and treated Causes – trauma, shock, infection, urinary obstruction, and multisystem diseases.  Renal Diseases Acute Kidney Injury (AKI) (cont.) Quick onset; deteriorating function includes decrease or cessation of urine output, which can cause uremia. Uremia may be associated with the following findings: Jodl's 2113,86142711 Generalized edema Acidosis If not recognized early and treated, can lead to heart failure volume overload, hyperkalemia, metabolic acidosis fluid overload high Concentration of potassium and uricacid Definition of Terms Uremia is a clinical condition associated with declining renal function and is characterized by fluid overload, electrolyte imbalances, metabolic abnormalities, and physiological changes  Renal Diseases Acute Kidney Injury (AKI) (cont.) Prerenal AKI Inadequate perfusion of the kidneys. Obstruction to renal arteries results in decreased blood flow to the kidneys. Patients are critically ill and may have preexisting medical conditions. Signs and symptoms: dizziness, dry mouth, thirst, hypotension. Treatment –improve kidney perfusion and function by treating the underlying condition.  Renal Diseases Acute Kidney Injury (AKI) (cont.) Intrarenal AKI Results from conditions that damage or injure one or both kidneys (e.g., tubular diseases). 90% of cases are caused by ischemia or toxins, and can lead to acute tubular necrosis. Associated with hypertension, autoimmune diseases and pyelonephritis. Signs and symptoms – fever, flank and joint pain, headache, and hypertension; in severe cases renal dialysis or kidney transplantation may be necessary.  Renal Diseases Acute Kidney Injury (AKI) (cont.) Postrenal AKI Caused by ureteral and urethral obstruction- obstructs the urine flow from both kidneys. Blockage of urine causes pressure to build in the renal nephrons and may shut down the nephrons. Signs and symptoms – urine retention, distended bladder, gross hematuria, lower back pain, pain in abdomen, groin or genitalia. Can be reversed by removing the obstruction to urine flow, or diverting the flow of urine. Treatment – nephrostomy tubes are placed through the patient’s back into the kidney, and connected to an external urinary collection bag. 16 Is S s www Renal Diseases Chronic Kidney Failure Progressive, irreversible systemic disease Develops over time; renal function declines, leads to end-stage renal disease requiring dialysis or kidney transplant. Possible cause - congenital disorders or prolonged pyelonephritis Kidneys compensate for renal damage by hyperfiltration causing further damage and loss of kidney function. Buildup of fluid and waste causes azotemia and uremia, and most body systems are affected. Complications include hypertension, heart failure, or anemia; once diagnosed treatments begin to delay or stop the progressive loss of kidney function.  Renal Diseases Chronic Kidney Failure (cont.) – End stage requires dialysis or transplantation – Six systemic manifestations: o Gastrointestinal – anorexia, vomiting, metallic taste o Cardiopulmonary – hypertension, pericarditis, o Nervous system – anxiety, delirium, hallucinations o Metabolic or endocrine – glucose intolerance, anemia o Personality changes – fatigue, mental dullness, o Signs of uremia – uremic frost” Uremic frost (FIGURE), caused by the formation of urea crystals on the skin (late finding), yellow skin – Treatment options – kidney replacement therapy, peritoneal dialysis, hemodialysis, supportive care. Renal Diseases Transplantation Can provide the best survival rate and quality of life Most transplanted kidneys do not function forever 10 years post-surgery, approximately 60% of living donor kidneys and just under half of deceased donor kidneys will still be functioning.  Renal Diseases Renal Dialysis Dialysis is a technique used to normalize blood chemistry and remove excess fluid in patients with acute or CRF. Dialysis also removes blood toxins in some patients who have taken a drug overdose. Two types: Hemodialysis Peritoneal dialysis Both techniques bring the patient’s blood into contact with a semipermeable membrane, across which water-soluble substances diffuse into a dialyzing fluid (dialysate). Renal Diseases Renal Dialysis (cont.) Hemodialysis Patient’s heparinized blood is pumped through a surgically constructed arteriovenous fistula or graft. Blood is taken from the arm and flows through a dialyzer machine that filters the blood through tiny filaments in a dialysis solution; blood is returned to the body. Performed 3 or more times per week at an outpatient dialysis center or hospital. Each session lasts 3-4 hours. Renal Diseases Arteriovenous shunt  Renal Diseases Renal Dialysis (cont.) Peritoneal Dialysis In peritoneal dialysis, the dialysis membrane is the patient’s own peritoneum (FIGURE). Using a temporary or permanently implanted catheter, usually 2 liters of dialysate are infused into the peritoneal cavity over a period of approximately 10 minutes, filling the space around the kidneys, intestines, liver, stomach, and spleen. Fluids move by osmosis, and solutes (creatinine, electrolytes, urea, uric acid) diffuse from the blood in the peritoneal capillaries into the dialysate during the dwell period (the period that the dialysis solution stays in the abdomen). Equilibration occurs after several hours and varies by patient. At this point, the dialysate is drained over a course of approximately 20 minutes. Two systems are used for peritoneal dialysis. Continuous ambulatory peritoneal dialysis is performed manually and has a dwell time of about 4 hours. Automated peritoneal dialysis uses a machine called a cycler that controls the inflow, dwell, and drainage of the dialysate. This method may perform in a 24-hour cycle or be set to work intermittently at night.  Renal Dialysis (cont.) Peritoneal Dialysis (cont.) Renal Slower than hemodialysis Diseases Complication – peritonitis, caused by an infection when proper aseptic technique is not used. Signs and symptoms – cloudy drainage, exit-site redness, tenderness, swelling, or pus May be performed regularly in the home by patient or family caregiver. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies May be due to the disease process or from complications of the dialysis. Vascular access problems. Bleeding at the site of puncture. Bleeding from graft or fistula is minimal but excessive pressure can cause thrombosis. If severe external hemorrhage occurs and cannot be controlled, apply a tourniquet. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Vascular access problems Pseudoaneurysm – dilation resembling an aneurysm occurring at the graft site. Occluded fistulas and grafts due to thrombus formation. Infection results from a puncture made during dialysis. Signs of infection include unexplained fever or malaise.  Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Hemorrhage Dialysis patients are at higher risk because of their exposure to anticoagulants during hemodialysis and decreased platelet function. Patients with hemorrhage from trauma or medical condition should be monitored closely for signs of hypovolemia. Anemia (common with dialysis) lowers patients’ ability to compensate for blood loss. Significant blood loss may produce dyspnea or angina. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Hypotension Occurs with hemodialysis. Patient may not be able to maintain normal blood pressure and must be managed cautiously with the administration of volume-expanding fluids. Avoid fluid overload which can cause hypertension and signs of heart failure. If patients do not respond, consider other serious causes. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Chest pain Results from episodes of hypotension and mild hypoxemia during dialysis. Symptoms are relieved by administration of oxygen, fluid replacement, and antianginal medications. Dysrhythmias due to myocardial ischemia may be associated with dialysis.  Renal Diseases Renal Dialysis (cont.) – Dialysis Emergencies (cont.) o Severe hyperkalemia – Life-threatening emergency resulting from poor dietary regulation and missed dialysis. – ECG shows a tall or tented T-wave. – Any patient with renal failure in cardiac arrest should be suspected of having severe hyperkalemia. – Treatment – physician may recommend separate administration of calcium and sodium bicarbonate during resuscitation. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Air embolism May enter the patient’s blood stream if there is negative pressure on the venous side of dialysis tubing or the machine malfunctions May travel to the right ventricle of the heart where it can block passage of the blood to the left myocardium. Patient requires a high concentration oxygen, infusion of IV fluid, and rapid transport to a medical facility. Renal Diseases Renal Dialysis (cont.) Dialysis Emergencies (cont.) Management Patients with chronic or acute renal failure: Provide airway and ventilatory support with supplemental high-concentration oxygen if hypoxic. Vascular access for fluid replacement, medication therapy, or fluid resuscitation if needed. ECG and other vital sign monitoring. Rapid transport to an appropriate medical facility with hyperbaric chamber. Urinary System Conditions Urinary System Conditions There are many types of urinary tract diseases, which can range from mild to severe. Urinary system disorders that may cause acute pain include urinary retention, urinary tract infection (cystitis, urethritis), pyelonephritis, and renal calculi. Similar to disorders of the abdomen, urinary system disorders may produce visceral, somatic, and referred pain Urinary System Conditions Urinary system disorders that may cause acute pain: I. Urinary retention” Inability to urinate” II. Urinary tract infection (cystitis, urethritis) III. Pyelonephritis IV. Renal calculi Urinary Retention Possible causes Urethral stricture Enlarged prostate (benign or malignant prostatic hypertrophy) CNS dysfunction Foreign body obstruction) prostatic enlargement, bladder stones, urethral stricture) or extrinsic (e.g., when a uterine or gastrointestinal mass compresses the bladder neck causing outlet obstruction). The bladder muscle can become so weak that it is unable to contract strongly enough to empty. Use of certain drugs such as parasympatholytic or anticholinergic agents ( decreasing bladder muscle contraction. Men are affected more often than women ; Most commonly due to enlarged prostate  Signs and symptoms of Urinary Urinary Retention Severe abdominal pain Retentio associated with urgent n need to urinate Distended bladder  Urinary Retention Patients with progressive obstruction often have history of Urinary hesitancy Poor urine stream Sense of incomplete emptying of bladder Nocturia (excessive urination at night) Overflow incontinence (overflow of urine from bladder) Urinary Retention May also cause delirium, especially in elderly patients In emergency department, passage of urethral catheter to empty bladder often required Urinary retention is painful for patient Prehospital care mainly is supportive – If abdominal pain is present, IV line to keep vein open may be indicated  Cause of retention should be sought, and if not easily correctable following physician examination, Urinary patient may require hospitalization Retention Some EMS systems may permit urinary catheterization in prehospital setting to empty patient's bladder.  Urinary Tract Infection (UTI) First develops in the lower urinary tract, may progress to upper tract if left untreated Common sites of lower UTI – urethra Urinary System and bladder Conditions UTI of urethra (urethritis) and bladder (cystitis) occurs when enteric flora (particularly Escherichia coli normally found in bowel) enter opening of urethra and colonize urinary tract More common in women because urethra is short and close to vagina and rectum  Urinary Tract Infection (UTI) Occurs in men (as a result of urethritis, prostatitis, and cystitis) and children Causes of UTI. Urinary Presence of renal stones A lower UTISystem Bladder catheterization. occurs when bacteria travel as high as the urethra or bladder. An upper UTI occurs when bacteria travel beyond this point and into the ureters or kidneys Suppressed immune system Conditions Wrong hygiene habits in females A lower UTI occurs when bacteria travel as high as the urethra or bladder. An upper UTI occurs when bacteria travel beyond this point and into the ureters or kidneys. Urinary System Conditions Urinary Tract Infection (UTI) Signs and symptoms Painful or difficult urination (dysuria) Urinary frequency Hematuria Cloudy or rust-colored urine (sometimes with unusual or foul odor) Flank or suprapubic abdominal pain Fever, chills, and malaise may be present Often patient will reveal history of UTI episodes Urinary System Conditions Urinary Tract Infection (UTI) Diagnosis confirmed in hospital through urinalysis and microscopic examination for blood cells, sediment, and bacteria. Generally treated with increase 3-4 L a day fluid intake and antibiotic therapy*(Ciprodar 500mg*3) Interpreting urine analysis test Urinary System Conditions Pyelonephritis Is inflammation of the kidney parenchyma (upper urinary tract). Most often occurs as result of lower UTI. Occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys. Bacterial infections may also be carried to one or both kidneys. May be carried through bloodstream or lymph glands from infection that began in bladder.  Urinary System Conditions Pyelonephritis More common in adult women. Acute episodes can be severe in elderly and immunosuppressed. May be complicated by systemic infection with signs and symptoms that include Fever Chills Flank pain Cloudy or bloody urine Nausea Vomiting  Pyelonephritis If left untreated, can progress to chronic condition that can Urinary last for months or years. System May lead to scarring and Conditions possible loss of kidney function. Therapeutic intervention consists primarily of antibiotics, fluid replacement, and sometimes hospitalization.  Urinary calculi (kidney stones) Pathological concretions that originate in renal pelvis. Urinary Most painful and most common disorders of urinary tract. System About 250,000 hospitalizations each Conditions year. 77 % of men and 3 % of women in U.S. will have kidney stone at some point in their lives. Urinary System Conditions Urinary Calculus Kidney stones result from supersaturation of the urine with insoluble salts. When level of insoluble salts or uric acid in urine is high, urine lacks citrate (chemical that normally inhibits formation of stones). If insufficient water in kidneys to dissolve waste products, kidney stones can form. Most common in men ages 20 to 50. Recurrent, more common in men than women.  Urinary System Conditions Urinary Calculus The chemical composition of the kidney stones depends on the chemical imbalance in the urine. Calcium oxalate (most common type of stones), account for about 85% of all kidney stones. They typically occur in patients with metabolic disorders (eg, gout) or hormonal disorders (eg, hyperparathyroidism) Uric acid, (common in men). Struvite stones (also known as infection stones) are more common in women and are often linked to chronic bacterial UTI or frequent bladder catheterization. Cystine, least common type. Risk factors – dehydration, drug use, and surgery.  Urinary System Conditions Urinary Calculus Most stones obstruct ureter at points of ureteral narrowing in their passage from kidneys to bladder. Signs and symptoms Acute pain accompanied by restlessness, nausea, and vomiting, Diaphoresis, Low-grade fever ,Hematuria – Dysuria. The pain originates in the flank area and radiates to the right or left lower abdominal quadrant, groin, and testes (in men). Prehospital care IV fluids, transport in a comfortable position, antiemetics, and pain management. Treatment – if the stone does not pass spontaneously, laser or Shock Wave Lithotripsy (ESWL) lithotripsy or surgical intervention may be required. Strategies for Preventing the Recurrence of Renal Calculi Increase water consumption. Avoid foods containing calcium oxalate (eg, chocolate, beets, okra, spinach, sweet potatoes). Eat food with calcium, but avoid calcium supplements. Avoid foods that raise uric acid levels (eg, sardines). Reduce uric acid by eating a low-protein diet. Limit salt intake to reduce the level of calcium oxalate in the urine Thank you