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CE ARTICLE T-waves. A T-wave at least two-thirds the height of the QRS complex is considered peaked and is typically present in all leads. If potassium levels exceed 8 mEq/L, the P-wave is lost, and the QRS begins to widen. Eventually the S and T waves begin to slope together into what is considered a sine wave. Management of hyperkalemia is discussed later. The last major cardiovascular problem patients with ESRD risk experiencing is pericarditis. Pericarditis may develop as a result of high uremic acid levels but may also develop if dialysis is inadequate and does not remove enough fluid or acids. When these conditions occur, high uremic levels (usually BUN is greater than 60 mg/ dL) cause inflammation of the pericardial sac. Pericarditis causes chest pain (often relieved by the tripod position) and ST segment changes in all areas of a 12-lead EKG, and may cause a fever. Listening to heart tones may reveal a friction rub. Maintain a high index of suspicion for pericarditis whenever patients with ESRD complain of chest pain, as up to 20% experience it at some point. The nervous system is also affected by ESRD as neurons are impaired and damaged, though the etiology of why is unclear. In the central nervous system, uremia-related dementia can occur. Peripherally, neuropathy and restless leg syndrome are common.7 Pulmonary edema is also common, especially when patients miss dialysis or consume too much water or sodium. Additionally, patients are at risk for experiencing pulmonary effusions. Tachypnea is common and should almost be anticipated in patients with ESRD as the body tries to compensate for a stressed cardiovascular system, and fast breathing also blows off extra carbon dioxide as a buffer mechanism for the presence of increased acids. In the gastrointestinal system, the constant fluctuation of fluid accumulation and then dumping by the body leads to regular bloating and cramping as builtup fluids third-space into the interstitial spaces of the GI tract. Patients often experience nausea, vomiting and chronic diarrhea, making malnutrition common. Inspect the skin for uremic frost as a sign of renal failure. It is the crystallized form of urea left on the body after the patient sweats. Uremic frost occurs when the body cannot keep up with urea elimi- before dialysis is acidotic, has excess toxins, electrolytes and high levels of any medications the patient may be taking. Dialysate is an alkalotic solution that "When hyperkalemia is suspected, look for profound EKG changes, including peaked T waves, loss of a P wave and a widened QRS complex." nation. It looks like a sandy or salty frost and is commonly seen in the eyelashes, lips, armpits and groin. Additionally, the skin is affected by chronic dryness, cracking and loss of elasticity.7 Dialysis Dialysis works by diffusion by placing a semipermeable membrane between the blood and dialysate (dialysis solution). Keep in mind that the patient's blood contains no sodium or potassium; it is concentrated with other metabolites too large to diffuse into the body. The absence of sodium and potassium allows both electrolytes to diffuse into dialysate. Peritoneal dialysis introduces dialysate through an implanted catheter and into the patient's peritoneal cavity, where it is left for several hours. In this case the body acts as the semipermeable membrane. After several hours of the You Protect Us, We Protect Your Fleet & Bottom Line! Reduce Insurance Premiums & Legal Costs Reduce Insurance Premiums & Legal Costs by using Dual-Vision™ to Absolve by using Dual-Vision™ to Absolve Your Drivers in Accidents Your Drivers in Accidents Compact, Low Cost, Continuous Dual Video Recording System Dual-Vision™ XC is a palm-sized automotive event recorder which mounts to any windshield. Dual-Vision™ XC records video data from one camera pointing forward and a second camera facing the driver and passengers. • No Monthly Fees • Self Managed Data • 2 Cameras In Single Enclosure • 160 Hours of Continuous Recording • Reinforces Safe Driving Habits • Built in GPS Mapping 1-800-227-2095 www.roscovision.com A Century of Automotive Vision Safety For More Information Circle 41 on Reader Service Card EMSWORLD.com | MARCH 2013 55