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CE ARTICLE providers should be prepared to manage. They also require special considerations for management in general. Any time you manage a patient with ESRD who complains of any illness, fatigue or fever, ask what site is used for their dialysis (if they receive it) and inspect it for signs of infection (redness, localized pain, warmth and/or pus around any wound or puncture site). Dialysis access sites are common infection sources, and SIRS and sepsis can rapidly develop. Special consideration is needed for patients being treated with peritoneal dialysis, as they are at an increased risk for peritonitis. During dialysis patients receive heparin to prevent clots from developing at the access site. Further, they are chronically coagulopathic and as a result may experience bleeding from their graft or fistula when the access catheters are removed. Bleeding from these sites may appear profuse but is easily controlled with well-aimed direct pressure on the small hole at the puncture site. Consider placing a rolled piece of gauze over the puncture and applying moderate pressure with your hand or a compressive dressing. If bleeding continues, the pressure is not adequate, and the bandage needs to be more directly applied. Do not simply add more bandages over the top, as these only serve to absorb more blood. Once bleeding is controlled, pressure may be required for 30–60 minutes for a clot to completely form. When requested to treat a patient with postdialysis bleeding, anticipate needing to maintain pressure on the bleeding site for the duration of the transport to the hospital. Following dialysis patients may experience dizziness and hypotension. In some cases more than six liters of fluid are removed from these patients' bodies. Following dialysis, judicious fluid boluses with normal saline are reasonable, but proceed cautiously, as the hypotension is most likely transient. Administer fluid to ESRD patients between dialysis appointments with caution and only after assessing for symptoms of dehydration or fluid overload. Dry skin, flat neck veins and dry mucous membranes suggest dehydration, while bulging neck veins, crackles on auscultation, peripheral edema and complaints of bloating indicate fluid overload. A fluid bolus is appropriate in the former but should be avoided in the latter. Patients with histories of missed dialysis or medication noncompliance are at risk for experiencing metabolic acidosis and electrolyte imbalances such as hyperkalemia. Consider presumptive treatment of these two conditions with any dialysis patient in cardiac arrest. This would include sodium bicarbonate (1 mEq/kg) for acidosis and calcium chloride (500 mg–1 g) for hyperkalemia. Proceed in accordance with local protocols; if this is not in yours, ask your medical director about it. IV access in the dialysis patient can be a challenge. Always attempt to establish peripheral access in a limb without a fistula or graft. If necessary, use the limb with an access site. There is debate over whether to access a graft or fistula during medical emergencies. The overall high infection and complication rate makes it reasonable to avoid accessing fistulas and grafts, and it should not be done without online medical direction. During cases such as cardiac or respiratory arrest or when a patient is in a critical condition, a fistula can be easily cannulated with a traditional IV needle; guidelines for this should be provided in local protocols. Impaired renal function affects medication metabolism and clearance time, so caution is advised with any medication administration. There are frequently questions regarding the effectiveness of furosemide in ESRD patients. Furosemide has been shown to be beneficial in reducing left ventricular preload through venous dilation within 15 minutes of administration in CKD patients.8 A 1992 study found that small doses of oral furosemide temporarily increased urine output over a 24-hour period without serious complications.9 But in a more recent study on ESRD patients undergoing peritoneal dialysis, furosemide had no effect on increasing urine output.10 What does this conflicting research suggest? There is a need for more data, and the decision to administer will be case-based and made in consultation with medical control. If there is pulmonary edema, consider vasodilating drugs as well as noninvasive positive-pressure ventilation. Conclusion Chronic kidney disease is a worsening epidemic in the United States and is complicated by many associated problems. When a patient develops ESRD, the only options for continued life are a kidney transplant or dialysis. Hemodialysis must be performed three times a week to maintain homeostasis within the body and eliminate toxins and metabolic wastes. Approach ESRD patient management carefully. These are complicated patients at high risk for cardiovascular and pulmonary emergencies. Prehospital interventions can manage symptoms, but transport to dialysis or an emergency department is generally necessary. REFERENCES 1. United States Renal Data System. 2012 Atlas of EndStage Renal Disease, www.usrds.org/atlas.aspx. 2. CDC. National Chronic Kidney Disease Fact Sheet 2010, www.cdc.gov/diabetes/pubs/pdf/kidney_Factsheet.pdf. 3. Organ Procurement and Transplantation Network, http:// optn.transplant.hrsa.gov. 4. CDC. Incidence of end-stage renal disease attributed to diabetes among persons diagnosed with diabetes. MMWR, 2010 Oct 29; 59(42): 1,361–66. 5. Arora P. Chronic Kidney Disease. Medscape, http:// emedicine.medscape.com/article/238798-overview. 6. Kidney Disease Outcomes Quality Initiative. KDOQI Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification, www.kidney. org/professionals/KDOQI/guidelines_ckd/toc.htm. 7. National Kidney and Urologic Disease Information Clearinghouse, http://kidney.niddk.nih.gov/index.aspx. 8. Schmieder RE, et al. Immediate hemodynamic response to furosemide in patients undergoing chronic hemodialysis. Am J Kidney Dis, 1987; 9(1): 55–59. 9. van Olden RW, van Meyel JJ, Gerlag PG. Acute and long-term effects of therapy with high-dose furosemide in chronic hemodialysis patients. Am J Nephrol, 1992; 12(5): 351–6. 10. Flinn A, Ledger S, Blake P. Effectiveness of furosemide in patients on peritoneal dialysis. CANNT J, 2006 Jul–Sep; 16(3): 40–4. Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for Vitalink/Airlink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org. Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. Contact him at sean. kivlehan@gmail.com. Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Jr. College, CA. Contact him at scottrsnyder@me.com. EMSWORLD.com | MARCH 2013 57