dr. Angela Puspita, Sp.

Em
• Anatomy
• Function
• Acute Renal Failure (ARF)
• Causes
• Symptoms
• Management
• Chronic Renal Failure (CRF)
• Causes
• Symptoms
• Dialysis
• 2 Kidneys
• 2 Ureters
• Bladder
• Urethra
• Detoxify blood
• Increase calcium absorption
• calcitriol
• Stimulate RBC production
• erythropoietin
• Regulate blood pressure and electrolyte balance
• renin
• Acute versus chronic
• Pre-renal, renal, post-renal
• Anuric, oliguric, polyuric
• Acute
• sudden onset
• rapid reduction in urine output
• Usually reversible
• Tubular cell death and regeneration
• Chronic
• Progressive
• Not reversible
• Nephron loss
• 75% of function can be lost before its noticeable
• Pre-renal = 55%

• Renal parenchymal (intrinsic)= 40%

• Post-renal = 5-15%
• Pre-renal =
• vomiting, diarrhea, poor fluid intake, fever, use of diuretics,
and heart failure
• cardiac failure, liver dysfunction, or septic shock
• Intrinsic/renal
• Interstitial nephritis, acute glomerulonephritis, tubular
necrosis, ischemia, toxins
• Post-renal =
• prostatic hypertrophy, cancer of the prostate or cervix, or
retroperitoneal disorders
• neurogenic bladder
• bilateral renal calculi, papillary necrosis, coagulated blood,
bladder carcinoma, and fungus
• Decrease urine output (70%)
• Edema, esp. lower extremity
• Mental changes
• Heart failure
• Nausea, vomiting
• Pruritus
• Anemia
• Tachypenic
• Cool, pale, moist skin
• Make/think about the diagnosis
• Treat life threatening conditions
• Identify the cause if possible
• Hypovolemia
• Toxic agents (drugs, myoglobin)
• Obstruction
• Treat reversible elements
• Hydrate
• Remove drug
• Relieve obstruction
• Hyperkalemia
• Volume overload
• Vascular access
• Weakness
• Lethargy
• Muscle cramps
• Paresthesias
• Hypoactive DTRs (Deep
Tedon Reflexes)
• Dysrhythmias
• K > 5.5 -6
• Tall, peaked T’s
• Wide QRS
• Prolong PR
• Diminished P
• Prolonged QT
• QRS-T merge – sine
wave
• Calcium gluconate (carbonate)
• Sodium Bicarbonate
• Insulin/glucose
• Kayexalate
• Lasix
• Albuterol
• Hemodialysis
• 150–200 cases per million people = new cases each year
• Chronic renal failure and ESRD affect more than 2 out of 1,000
people in the U.S
• Mortality = 20%
• Diabetic Nephropathy
• Hypertension
• Glomerulonephritis
• HIV nephropathy
• Reflux nephropathy in children
• Polycystic kidney disease
• Kidney infections & obstructions
• Malaise • Seizure
• Weakness • Constipation
• Fatigue • Peptic ulceration
• Neuropathy • Diverticulosis
• Anemia
• CHF
• Pruritus
• Anorexia
• Jaundice
• Nausea • Abnormal hemostasis
• Vomiting
• Relating to underlying disease
• Relating to ESRD
• Dialysis related problems
• Metabolic – K/Ca
• Volume overload
• Anemia, platelet disorder, GI bleed
• HTN, pericarditis
• Peripheral neuropathy, dialysis dementia
• Abnormal immune function
• ½ of patients with CRF eventually require dialysis
• Diffuse harmful waste out of body
• Control BP
• Keep safe level of chemicals in body
• 2 types
• Hemodialysis
• Peritoneal dialysis
• Indications
• A for metabolic acidemia
• E for medically irremediable electrolyte abnormalities
• I for intoxications (eth glycol> 50 mg/dL, Li>4 mEq/L)
• O for volume overload
• U for uremia
• Understanding timing
• Call your friendly renal consult early
• Lightheaded –give fluids
• Hypotension
• Dysrhythmias
• Disequilibration Syndrome
• At end of early sessions
• Confusion, tremor, seizure
• Due to decrease concentration of blood versus brain leading to cerebral
edema
A. two kidneys, two ureters, one urethra
B. two kidneys, one ureter, one bladder, one urethra
C. one kidney, two ureters, one bladder, one urethra
D. two kidneys, two ureters, one bladder, one urethra
A. Ureter
B. Bladder
C. Nephron
D. Trigone
A. Oxygen 15 LPM/NRBM, rapid transport
B. Oxygen 15 LPM/NRBM, check blood glucose, rapid
transport
C. Have the patient’s daughter sign refusal and call in to
medical control
A. Blood pressure has no effect on kidney function.
B. Low blood pressure causes damage to the ureter
preventing urine from draining into the bladder.
C. Low blood pressure prevents adequate blood flow
through kidneys causing kidney tissue damage.
D. Low blood pressure stimulates arteries to dilate
causing an increase in the amount of blood flow
through the kidneys.
A. Take blood pressure and pulse in the left arm.
B. Take blood pressure in the right arm.
C. Take pulse in the right arm, blood pressure
measurement is not necessary in dialysis
patients.
D. Call for Med Flight. ALS ambulance agencies
cannot transport patients with an AV shunt.
A. Hypovolemic shock
B. Chemical exposure
C. Obstruction by kidney stone
D. All of these
8. a. SVT aberancy
b. Ventrilar Takikardia
c. Hiperkalemia
d. Sinus takikardia
e. STEMI
9. a. SVT aberancy
b. Ventrilar Takikardia
c. Hiperkalemia
d. Sinus takikardia
e. STEMI
10. a. asidosis metabolic
b. asidosis respiratoric
c. alkalosis metabolic
d. alkalosis respiratoric
e. alkalosis respiratorik
compensated
• ESRD patients
• Anemia
• Hypertension
• Edema / chimino shunt
• GFR < 15 for 3 months at min
• Dialysis Patients ( Hemodialysis or CAPD )
• Uremia
• Hyperkalemia
• Fluid Overload
• Contamination of blood with urine
• usually develops only after the creatinine clearance falls to less
than 10mL/min
Mild
 potassium level < 6 mmol / L
ECG may be normal or show only peaked T waves
Moderate
Potassium level between 6 – 7 mmol / L
ECG may show peaked T levels
Severe
Potassium level between 7 – 8 mmol / L
ECG flattening P wave and QRS with T wave ( sine wave ) → A
Lead to AV dissociation, disritmia and death
• Decreased or impaired potassium excretion
• Additions of potassium into extracellular space
• Transmembrane shifts (ie, shifting potassium from the
intracellular to extracellular space)
• Factitious or pseudohyperkalemia
Peaked T waves
Loss of P wave
Widening of QRS
ST depression
Prolonged PR interval
Ventricular dysrhythmias
Cardiac arrest
• ABC
• (1) reduction of pulmonary venous return (preload reduction),
• GTN
• Morphine
• Furosemide
• Nesiritide
(2) reduction of systemic vascular resistance (afterload
reduction), and, in some cases,
ACE inhibitors
ARB
nitroprusside

(3) inotropic support.

Dobutamine
Dopamine
Norephinephrine
PDI ( phospodiesterase inhibitor )
• The most common reasons for emergency dialysis are
• Uremia, including pericaridits and encephalopathy
• Hyperkalemia,
• Severe acid-base disturbances, and
• Pulmonary edema resistant to alternative therapy
• Some Poisoning, example methanol
1. Guide to the Essentials in Emergency Medicine. 2nd edition. 2015 : Hal 422
- 430.
2. Tintinally’s Emergency Medicine. 7th Edition. 2014
3. Rosen’s Emergency Medicine. 8th edition. 2014 : chapter 93
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