1. The Medical Patient The Renal System; Hypertensive Emergencies
Condell Medical Center
EMS System
October 2008 CE
Site Code # E1208
Prepared by: Sharon Hopkins, RN, BSN, EMT-P

2. Objectives
Upon successful completion of this module, the EMS provider should be able to:
List the components and function of the urinary system
State signs and symptoms of chronic kidney disease
Define hemodialysis
Identify the differences between AV fistulas and AV shunts & implications in the field
Apply the Renal SOP’s given a scenario
List the steps in performing an abdominal assessment

3. Describe the physical assessment of the patient with flank pain
Describe the management of the patient with flank pain
Define the criteria for a hypertensive emergency
List the signs and symptoms of hypertensive emergencies
Describe the rationale for treatment using Lasix and Nitroglycerin for hypertensive emergencies
Describe the proper technique to obtain a blood pressure
Describe the components of a neurological assessment

4. Successfully calculate the GCS given the findings of the patient assessment
Return demonstrate pupillary assessment
Return demonstrate the in-line Albuterol set-up
Return demonstrate the preparation of an Amiodarone IVPB set-up
Identify and appropriately state interventions for a variety of EKG rhythms
Identify ST elevation on a 12 lead EKG
Successfully complete the 10 question quiz with a score of 80% or better

5. Urinary System Contains 4 major structures Kidneys Vital organs
Located in upper abdomen; retroperitoneal area
1 behind the spleen; 1 behind the liver
Ureters
Urinary bladder
Urethra

7. Function of the Urinary System
Major functions
Maintains blood volume via proper balance of water, electrolytes, and pH
Retains key compounds (ie: glucose) and eliminates wastes (ie: urea)
Monitors and maintains arterial blood pressure (in addition to other mechanisms)
Regulates erythrocyte (RBC) development

8. Urinary Bladder
Storage receptacle for the production of urine until it is convenient or necessary to void
Fully distended can hold 500 ml of urine
The more distended the bladder, the more vulnerable to blunt trauma
After urination, the bladder contains about 10 ml of fluid

9. Chronic Kidney Disease
Can be from a specific kidney disease or as a complication from other conditions
Diabetes
#1 reason in USA for need for kidney transplant
Hypertension
Kidney inflammation (glomerulonephritis)
Inflammation of blood vessels (vasculitis)
Polycystic kidney disease

10. Chronic Kidney Disease
Diseased or injured kidneys
Blood flow through the renal system decreases
Inflammatory changes occur in the glomeruli
A group of capillaries where blood is filtered into a nephron (structure that produces urine)
Capillary walls thicken decreasing permeability
Glomerular filtration rate (GFR) is reduced
Volume of blood filtered per day thru glomeruli

11. Symptoms of Chronic Kidney Disease
Most common symptoms
Swelling, usually of lower extremities
Fatigue
Weight loss, loss of appetite
Nausea and/or vomiting
Change in urination
Reduction in volume or frequency
Change in sleep patterns
Headache
Itching – high levels of phosphorus in system; dry skin
Difficulties with memory or concentration

12. Complications of Chronic Kidney Disease
Hypertension
May be a leading cause but can also develop in the early stages as a complication
Anemia
Decreased production of red blood cells
Bone disease
Disorders of calcium and phosphorus
Malnutrition
Altered functional status and well-being

13. Dialysis
Dialysis is required when the kidneys fail and a transplant is not performed
Peritoneal dialysis uses a catheter thru the abdominal wall to filter the blood

14. Hemodialysis
Hemodialysis is a procedure in which a machine filters harmful waste and excess salt and fluid from your body
Access points are created to be functional within weeks and to last several to many years
Usual access point is the forearm

15. Fistulas and Shunts Arteriovenous (AV) fistula
Most common type of access
Fistula created internally by sewing an artery to a vein forming a small opening between the two
Pressure from the arterial flow eventually enlarges and strengthens the vein
May take 6 weeks to heal but can last for years

17. Arteriovenous (AV) graft
Access is similar to a fistula
A synthetic tube is used to surgically connect the artery to the vein
AV graft often heals within 2-3 weeks
With proper care, can last several years
Higher likelihood of forming clots or becoming infected than an AV fistula

18. Renal Dialysis

19. Hemodialysis Most people treated with hemodialysis 3 times a week
Each session lasts approximately 3-5 hours
Some patients, at some dialysis centers, may choose daily dialysis
Usually performed 6 days per week for 2 – 21/2 hours each session
Patients often report improved B/P and quality of life

20. Continuous Ambulatory Peritoneal Dialysis
CAPD is a self-care treatment where the patient instills dialysate fluid into the peritoneal (abdominal) cavity through a surgically implanted catheter through the abdominal wall
The dialysate stays in the abdominal cavity a prescribed period of time and then is drained out

21. CAPD Instructions Do not disconnect the CAPD bags from the catheter
If the patient is transported, transport with the drainage bag remaining below the level of the patient’s waist
Do not infuse any fluids or medications directly into the catheter
This IS NOT an alternate IV site
Transport the patient with the CAPD intact

22. Renal Protocol Care of Patients with Grafts or Shunts
Do NOT take B/P on arm with active fistula or graft
Do NOT start IV on arm with active fistula or graft
If site is bleeding, apply direct pressure
In case of arrest and no IV access consider IO site
Access of fistula or graft is only with contact to Medical Control

23. Care of The Renal Patient
Best to err on the side of conservative treatment
Monitor and support the ABC’s
High flow O2 is appropriate to maximize respiratory efficiency
Carefully monitor fluid administration
Monitor cardiac rhythm for disturbances
Caregivers can help manage the additional equipment on the patient

24. Abdominal Pain Assessment
Chief complaint
The sign or symptoms that prompted the patient to call for help
Use an open – ended question to determine the reason for the call
“Why did you call us today?” or
“What seems to be the problem?”
During the interview the chief complaint generally becomes more specific

25. Assessment O – onset of the problem P – provocation/palliation
Did problem start suddenly or gradually?
What was patient doing at the time?
P – provocation/palliation
What makes the symptoms worse? Better?
Q – quality
In the patient’s own words how do they describe their pain (ie: crushing, tearing, sharp, dull?)

26. R – region/radiation Where is the symptom? Does it move?
If the patient uses one finger or isolates to one spot, the pain is considered localized
If the pain is described using both hands or indicating a larger area, the pain is diffuse
Is there referred pain (pain felt in a body area away from the source)?

27. S – severity T – time Intensity of pain or discomfort 0 – 10 scale
“0” is no pain; “10” is the worse pain in your life
Can the patient be distracted?
Do they lie still or are they writhing about?
T – time
When did the symptoms begin?

28. Associated symptoms Pertinent negatives
Are other symptoms present that are commonly linked to certain diseases that can help rule in or out your diagnosis?
Pertinent negatives
Are any likely associated symptoms absent?
Absence of symptoms can be information as helpful as presence of other symptoms

29. Assessment Pitfalls in the Chronic Renal Patient
The challenge to the medical professional is to separate the acute complaint from the chronic condition
What is new today that changes your status?
Many of these patients have unstable baselines to start with
Fluid and electrolyte imbalance
EKG disturbances

30. Physical Assessment - Abdomen
Boundaries run from xiphoid process to symphysis pubis
A full bladder will distort assessment and increase discomfort for the patient
To relax the abdominal wall or to ease pain, a pillow placed under the knees would be helpful
Start by asking the patient where it hurts
Examine painful areas last

31. Warm your hands and stethoscope
If hands are cold, palpate over clothing until hands warm up
Monitor facial expressions for pain or discomfort
Validate the facial expression
Often the patient scrunches their face in anticipation of pain
Assessment techniques to use
Inspection, auscultation, percussion, lastly palpation

32. Abdominal Assessment Techniques
Inspection
A visual review looking for abnormalities
Auscultation
Move the stethoscope in a circle approximately 2 inches from the umbilicus listening for bowel sounds
Normal bowel sounds gurgle approximately every 5-15 seconds

33. Percussion
Not often performed in the field
Helps determine size and location of organs
Determines gas, solid, and fluid filled areas
Tympany heard over most of abdomen
Dullness percussed over spleen and liver

34. Palpation
Palpate painful areas last
To increase comfort to patient, have them take slow, deep breaths thru open mouth
Flexing knees relaxes abdominal wall
Abdominal pain on light palpation indicates peritoneal irritation or inflammation
Voluntary guarding – patient anticipates pain or is not relaxed
Involuntary guarding – peritoneal inflammation (lining of abdominal cavity)

35. SOP Abdominal Pain Stable Patient
Routine medical care
Watch the patient for vomiting
Stable patient
Patient alert
Skin warm and dry
Systolic B/P > 100 mmHg
Contact Medical Control for pain management

36. SOP Abdominal Pain Unstable Patient
Routine medical care
Watch the patient for vomiting
Unstable patient
Altered mental status
Systolic B/P < 100 mmHg
Establish IV; x2 if possible
Fluid challenge in 200 ml increments
20 ml/kg in pediatric patient (max 3 challenges)
Contact Medical control for pain management

37. Flank Pain Where’s the flank? What organs lie in the flank areas?
The area of the back below the ribs and above the hip bones
What organs lie in the flank areas?
The kidneys
What is a common reason for flank pain?
Renal calculi (aka kidney stones)

39. Causes of flank pain

40. Kidney Stones
The formation of crystals in the kidney’s collection system
Hospitalization common for pain control and fluid hydration
Additional inpatient treatment may be necessary
Lithotripsy – sound waves used to break apart larger stones into smaller ones that can be passed during urination

41. Kidney Stones More common in males Suggestion of hereditary patterns
Risk factors include immobility and certain medications (anesthetics, opiates, psychotropic drugs)
Stones can form in metabolic disorders (ie: gout)
Production of excessive uric acid and calcium

42. Stones From Calcium Salts
The most common type of stone
75 – 85% of all stones
Calcium stones 2 – 3 times more common in men
Average age of onset 20 – 30 years
Familial indication
History of one stone and patient likely to form another one within 2 – 3 years

43. Struvite Stones Represent 10 – 15% of all stones
Formation associated with chronic urinary tract infection or frequent bladder catheterization
Patients with spinal cord injuries
Patients with spina bifida
More common in women (due to their higher incidence of UTI’s)

44. Uric Acid Stones The least common of all stones Form more often in men
Tend to occur with family histories so most likely a hereditary component
Half of patients with uric acid stones have gout

45. Patient Assessment Chief complaint almost always severe pain
Kidney stones considered to be the most painful medical condition
Pain started vague, dull, poorly localized (visceral pain) in one flank
Within 30 – 60 minutes pain is extremely sharp, remains in the flank and radiates downward and anteriorly to the groin

46. Physical Exam Agitated, restless, uncomfortable patient
B/P and heart rate elevated with the pain
Skin typically pale, cool, clammy
Patient may not be able to lie still for abdominal examination
Observed urine sample may have gross hematuria or will be evident in lab analysis

47. Management Position of comfort Be prepared for vomiting (due to pain)
IV fluids for volume replacement and as a drug route, and to promote urine formation and movement through the system to flush through the stone
Analgesia for pain – limited amounts used in the field often have minimal effect, if at all

48. SOP Flank Pain SOP treatment same as abdominal pain
Call Medical Control to obtain pain medication orders
Be patient’s advocate for pain control
Kidney stones are considered the most painful human condition (just ask someone who has had one!)

49. Hypertensive Emergency
A life-threatening crisis with an acute elevation of the blood pressure
Systolic B/P > 230 mmHg
Diastolic B/P > 120 mmHg
Usually seen in patients with untreated or poorly controlled hypertension

50. Hypertensive Emergency
Signs and symptoms
Epistaxis – nosebleed
The nasal tissue is very thin and prone to bleed
Headache
“The worst headache in my life” often indicates a subarachnoid bleed
Visual disturbances (ie: blurred, blindness)

51. Restlessness
Confusion
Nausea and vomiting
Neurologicial changes
Altered mental status to seizures to coma
Complications
Hypertensive encephalopathy
Severe headache, vomiting, visual changes, paralysis, seizures, stupor, coma
Ischemic (clot) or hemorrhagic (bleed) stroke

52. Field Assessment Chief complaint received is often headache
Additional accompanying complaints
Nausea and/or vomiting
Blurred vision
Shortness of breath
Epistaxis (nosebleed)
Vertigo (dizziness)
Level of consciousness may be normal, altered, or patient may be unconscious

53. Field Assessment Findings Skin may be pale, flushed, or normal
Skin may be warm or cool; moist or dry
If hypertensive encephalopathy is present, it may cause left ventricular failure
Patient will be in pulmonary edema
Lung sounds clear unless in pulmonary edema
Pulse often strong and bounding

54. SOP - Hypertensive Emergency
Routine Medical Care
Obtain and record the B/P in both arms
Monitor & record vital signs and neuro status every 5 minutes
Lasix 40 mg IVP
80mg if already on Lasix at home
Contact Medical control for further orders
Possible Nitroglycerin order

55. Treating Hypertensive Emergencies
Initial goal
To achieve a progressive, controlled reduction in the blood pressure to minimize risks of hypoperfusion in the vascular beds in cerebral, coronary, and renal blood flow
Goal is not to reduce the blood pressure to “normal” levels as fast as possible

56. Why Give Lasix? Lasix is a venodilator and a diuretic
By dilating blood vessels, blood pressure can be decreased
Venodilator effect noticed before evidence of diuretic effects are seen
Decreasing fluid volume is another method to reduce the blood pressure by reducing the volume to be pumped

57. Why Give Nitroglycerin
Primarily a venodilator
Will dilate the diameter of blood vessels
Decreases blood pressure
Especially useful in the patient with coronary ischemia
Still need to screen for use of Viagra or Viagra type drugs in the past hours

58. Obtaining A Blood Pressure

59. Blood Pressure Measurement
Poor technique can result in inaccurate values
Patient’s arm should be at the same vertical height as the heart
The cuff bladder should fit snugly around the arm
The lower edge of the cuff should be placed 1 inch above the brachial artery
The bladder should be centered over the brachial artery

60. The bell end of the stethoscope will produce better sounds
The diaphragm is easier to place and hold with one hand
The cuff and tubing should not be touching clothes which can give false sounds
After the cuff is pumped up, the air should be released slowly
Air released too fast may cause an inaccurate measurement to be read
Cracked tubing causes air to leak too fast

61. Obese Site & B/P Cuff Wrap the blood pressure cuff around the forearm
Center the bladder over the radial artery
Place the stethoscope over the radial artery
Obtain and document the blood pressure in the usual manner (ie: 120/80)

62. Blood Pressure by Palpation
Rough estimation of the systolic value
Palpate for the loss of the radial or brachial pulse and continue to inflate the cuff an additional 30 points
Slowly release the air and when the pulse is first felt, this is the recorded systolic B/P
Document the reading as “100/palpation”

63. Rough Estimate of Blood Pressure By Palpation
A rough guideline; accuracy is debatable
If the radial pulse is palpated, the B/P is said to be roughly 80 mmHg
If the femoral pulse is palpated, the B/P is said to be roughly 70 mmHg
If only the carotid (central) pulse is felt, the B/P is said to be roughly 60 mmHg

64. A “Neuro” Assessment Level of consciousness
A – alert (means awake but not necessarily oriented; spontaneous eye opening; responds to voice but can be confused; and has motor function )
V – responds to verbal command no matter how slight and type of response
P – responds to pain or tactile stimuli only
U – unresponsive with no eye, voice, or motor response at all to voice or pain

65. Ask 2 questions to determine level of consciousness
“What month is this?”
“How old are you?”
Obtain the Glasgow Coma Scale (GCS) on all EMS patients
Best eye opening (4 points)
Best verbal response (5 points)
Best motor response (6 points)
Evaluate pupillary response

66. Performing a Pupillary Check
Ask patient to focus on an object (ie: tip of your nose)
Bring the light in from the side and out the same way
Without shining in the eyes move the penlight into position for the opposite side and repeat

67. Check muscle tone and strength Evaluate facial symmetry (smile)
Vital signs
Signs of increasing intracranial pressure include increasing B/P and dropping heart rate
Check muscle tone and strength
Evaluate facial symmetry (smile)
Evaluate clarity of speech
The above 3 are the Cincinnati Stroke Scale
Arm drift, facial symmetry, speech
Additionally:
Coordination or gait and sensory
Movement and sensation

68. Repeat Assessment
If you want to see where the patient is going, you’ve got to know where they’re coming from
GET A BASELINE EVALUATION
You can anticipate something happening if you are watching the trends
PERFORM REPEAT ASSESSMENTS AS OFTEN AS INDICATED
Prevents surprises

69. Need to constantly monitor the situation
Watch for trends
Anticipate surprises

70. Pain Management SOP Routine trauma or medical care
Continuous patient monitoring
Respiratory status
SaO2
Blood pressure
Morphine
2 mg slow IVP over 2 minutes
May repeat every 2 minutes
Maximum total 10 mg

71. Respiratory Depression Related to Morphine Use
Supportive oxygenation
If SaO2 is falling and ventilation rates are declining, consider supportive bagging
Ventilation rates for supportive bagging (AHA)
Adult 1 breath every 5 – 6 seconds
Pediatric patients 8 and less 1 breath every 3 – 5 seconds
Narcan (narcotic antagonist)
2 mg IVP if respiratory depression

72. Glasgow Coma Scale Exercise
Review the following 3 patient’s assessment findings
Evaluate for their GCS
Determine the best response and score the patients
Best eye opening points
Best verbal response 1 – 5 points
Best motor response points
Note: GCS to be obtained on all patients!

73. GCS Exercise #1 You are assessing a 56 year-old patient
The patient is unresponsive. Nothing happens when you call the patient’s name. when you pinch the patient, their eyes open, then close.
When pinched, the patient says “don’t, stop” and then is silent.
When pinched, the patient pushes you away

74. GCS Exercise #2 Your patient is a 16 year-old male.
Upon approaching, the patient’s eyes are open and they are looking around with an anxious look.
They do not answer questions; they groan if pinched.
They do not follow commands. When touched, the patient grabs your arm and doesn’t let go.

75. GCS Exercise #3 Your patient is an 8 month-old.
Their eyes are closed. There is no response to pinching.
When pinched, the patient groans weakly.
When pinched, the patient tries to pull away or turn away from the evaluator.

76. GCS Exercise Answers GCS #1 total –11 GCS #2 total – 11
Eye opening – 2
Verbal response – 4
Motor response – 5
GCS #2 total – 11
Eye opening – 4
Verbal response – 2
Motor response - 5
GCS #3 total – 7
Eye opening – 1
Verbal response – 2
(groans to pain – incomprehensible words)
Motor response – 4
(withdraws to pain)

77. Skill – In-line Albuterol
For Albuterol to have its bronchodilating effects, it must be delivered down into the lungs
If the patient can’t inhale it in, we have to push it in

78. Normal use with corrugated tubing connected to the T-piece
Kit connected to oxygen and run at 6 l/minute (enough to create a mist).
Nebulizer kept upright at all times.

79. In-line Albuterol Intubate the patient
While waiting to intubate, can “bag” the Albuterol into the lungs via in-line set-up thru ambu mask
Confirm placement in the usual manner
visualization
chest rise & fall
5 point auscultation
ETCO2 detector
Evaluated after 6 breaths are delivered

80. To adapt nebulizer to in-line use:
Remove mouthpiece from T-piece and replace with BVM
Connect nebulizer to oxygen source

81. Corrugated tubing left in place on T-piece
Clear adaptor placed on distal end of corrugated tubing
Once intubated, clear adaptor connected to ETT

82. The BVM helps push the Albuterol where it will do the most good.
Albuterol will be effective if it gets into the bronchial system, not just into the back of the throat.
The BVM helps push the Albuterol where it will do the most good.

83. EKG Review & Treatment There is NO pulse!!! The patient has no pulse!
6 second strip
The
patient
has
no pulse!

84. EKG Interpretation #1 PEA with a rate over 60 CPR Secure airway
Search for causes (6 H’s; 5 T’s)
Establish IV/IO access
Epinephrine 1:10,000 1 mg IVP/IO every 3-5 minutes
No Atropine – rate over 60

85. 6 H’s Hypovolemia – fluid challenge Hypoxia – supplemented oxygen flow
Hydrogen ion – acidosis – ventilate (breathe) for the patient
Hyper/Hypokalemia – electrolyte imbalance
Hypothermia – warm them up
Hypoglycemia – screen all unconscious/altered level of consciousness patients for glucose level

86. 5 T’s
Toxins – think little kids getting into the wrong places (ie: purses, cabinets)
Tamponade, cardiac
Tension pneumothorax – needle decompression
Thrombosis, coronary
Thrombosis, pulmonary (embolism)
Trauma

87. EKG Review & Treatment

88. EKG Interpretation #2 Strip A – complete heart block
Strip B – paced rhythm
Unstable Type II and 3rd degree heart blocks
Patient often unstable due to slow heart rate
Begin TCP
Rate: 80/minute
Sensitivity: auto/demand
Output: lowest mA until capture

89. Comfort Measures For TCP
Valium 2 mg IVP slowly over 2 minutes
May repeat 2 mg IVP every 2 minutes
Maximum of 10 mg
Can touch the patient and not receive shocks
It’s the patient that feels the electrical stimulation

90. EKG Review & Treatment

91. EKG Interpretation #3 VT – wide complex, until proven otherwise, is VT
2 questions to ask for all tachycardias
Question #1 – is patient stable or unstable
Evaluate LOC and B/P
If you are not perfusing, you cannot maintain an adequate level of consciousness or blood pressure
If unstable, prepare for immediate cardioversion
If stable, ask question #2

92. 2nd Question To Ask if Stable Tachycardia
Question #2 – is complex (QRS) narrow or wide?
Narrow think SVT
Adenosine is drug of choice
Wide think VT
EMS choice between Amiodarone or Lidocaine
Mixing the antidysrhythmics makes the heart more irritable
Let the ED know which drug therapy was started

93. If stable VT Antidysrhythmic treatment
Amiodarone 150 mg diluted in 100 ml D5W IVPB
Draw up Amiodarone dose, add to 100 ml D5W IV bag and gently agitate to mix; label the bag (drug, amount, time added)
Run thru mini-drip tubing; piggyback into the primary IV line
Run over 10 minutes (rapid drip rate just below wide open)
OR Lidocaine 0.75 mg/kg IVP x1
Contact Medical Control for further orders

94. EKG Review & Treatment

95. EKG Interpretation #4 Sinus bradycardia
If symptomatic/unstable (poor cardiac output with altered mental status and B/P <100)
Atropine 0.5 mg rapid IVP
“When they’re alive give them 0.5”
May repeat every 3-5 minutes to a max of 3 mg
If ineffective begin TCP
If TCP ineffective, treat per Cardiogenic Shock
IV fluid challenge in 200 ml increments, Dopamine drip

96. Where’s ST elevation?

97. 12 Lead Interpretation #1 ST elevation in exercise #1
V1 – V3
12 lead obtained in field
EMS to evaluate the 12 lead looking for patterns of ST elevation
I, aVL, V5, V6
II, III, aVF
Any contiguous V leads
EMS to call in what they see & fax the 12 lead

98. Where’s the ST elevation?

99. 12 Lead Interpretation #2 ST elevation in exercise #2
V2 – V4
12 lead obtained in field
EMS to evaluate the 12 lead looking for patterns of ST elevation
I, aVL, V5, V6
II, III, aVF
Any contiguous V leads
EMS to call in what they see & fax the 12 lead

100. Where’s the ST elevation?

101. 12 Lead Interpretation #3 ST elevation in exercise #3
II, III, aVF
12 lead obtained in field
EMS to evaluate the 12 lead looking for patterns of ST elevation
I, aVL, V5, V6
Any contiguous V leads
EMS to call in what they see & fax the 12 lead

102. Bibliography
Bledsoe, Porter, Cherry. Paramedic Care; Principles & Practices. 3rd Edition. Brady
Burrows-Hudson, S. Chronic Kidney Disease. AJN. Feb Vol 105, No2.