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Trauma, your dead, now what, acute kidney injury (AKI), Abdominal trauma,…
Trauma
prehospital resuscitation
control of external bleeding and shock
immobilization
airway maintenance
jaw thrust if neck injury suspected
immediate transport (ground or air)
golden period
increase time without care = increased death
immediately stabilize and transport
complications
shock stages
MODS
sepsis
ARDS
emergency department resuscitation
primary survey
CABDEF
disability
neuro focus
exposure
cut of cloths to look at every part of skin
breathing
FAST
Focused Assessment with Sonography in Trauma
airway (if they are crying/screaming they have one)
Circulation exsanguination, pulses, bleeding control
palpable...
radial pulse: SBP 80
brachial pulse SBP 70
central pulse SBP 60
fix whats going to kill them first which is usually C
Secondary survey
AMPLE
past illness/pregnancy
last meal
medications
events/environment related to injury
allergies
other info
MVC extraction time
speed
seat belt use
ejection?
location in vehicle (driver, front seat, back seat)
direction of impact (head on, t bone, rear end)
mechanism of action
blunt trauma
penetrating injuries
critical care phase
definitive care/operative care
advanced trauma life support guidelines
permissive hypotension
MAP goal
+50
patients with TBI need MAP 80+ for CCP
assess for triad of brain
hypothermia, acidosis, coagulopathy
tetaus boost if needed
1:1:1 infusions with PRBC (o2), plasma (clotting), platelets (stop bleed)
urinary cath
look for blood
balance fluid resuscitation with warmed LR and NS
manage focused injuries
family presence is good
your dead, now what
What to Expect When Your Patient Becomes a Donor
potential donor recognized
organ referral call made to Organ Procurement Organization (OPO) Midwest
Transplant Network (MTN) coordinator
call before DR or deceleration of care or if Glasgow <5 patient progresses to meet brain death criteria
MTN coordinator comes to hospital brain death testing begins by physician official brain death pronouncement
plan developed for family approach by all team members - involve chaplain or social worker who the family knows
consent for donation obtained
testing and allocation by MTN
organ donor management
organs evaluated
nurse doesn't talk to family! MTN rep does!
Donation after Cardiac Death (DCD)
pt is deemed a candidate for DCD by OPO staff
plan developed for family approach by all team members
referral made to OPO - OPO coordinator comes to hospital to evaluate
consent is granted (unless first person authorization already in place)
family makes decision to d/c or withdrawal care
organ donor testing and allocation by OPO
patient is not brain dead and is not likely to progress to brain death
removal of ventilator (patient must die via cardiac death within 60 minutes)
cardiac death
procurement
Organs that are potential donations with DCD are lungs, liver, kidneys and possibly pancreas
Initial Donor Orders
VS/I&0 q hour, including Sa02 and temp
IVF orders
Routine lab work, serology tests
Culture blood, urine, sputum
Broad spectrum antibiotic coverage
ABO blood typing, height and weight
Initiate aggressive respiratory care
SG/Central/arterial line placement lymph node recovery for tissue typing
Cardiac/pulmonary evaluation
height and wt because some organs have to be similar size
Some challenges to expect...and care needed
Hypothermia
due to lack of functioning hypothalamus, goal is temp > 35
use warming blanket, air warmer, warm IV fluids
Diabetes insipidus
due to lack of ADH secretion
1000+ cc/hr of urine
give ADH (vasopressin)
pituitary not working
hypotension
inability to control vasomotor tone
hypovolemia
use IVF, LR is preferred
use pressors with cautiously due to cardiac stress
pulmonary artery catheter
most accurate means of assessing volume status
All donors must have at least
Arterial line
CVP
best indicator of cardiac capability and organ perfusion after brain death
other hormone replacement needs
steroids
thyroxine
insulin
Electrolyte imbalances
Loss of K+, phos, mag
correct as needed, reassess frequently
may need to dialyze
DIC
(25% of organ donors) - esp with penetrating head wounds
FFP and blood products, heparin - controversial
replace what they need
Neurogenic pulmonary edema
Disruption of capillary bed during brain death = leaky lung capillaries
pulmonary toilet
hourly hyperinflation (sigh) & suction
ventilator - use lowest tidal volume, Fi02 & PEEP possible good oral care & subglottic suctioning
turn patient g 1-2 hrs if VS tolerate or CPT/automatic turn beds
respiratory treatments: Albuterol MDI g 2-4 hrs
prone especially if they are lung donor
initially tachycardia, hyerptesion, vasoconstiction, hyperglycemia
give beta blockers, vasodilators, insulin for organ donation
Approximate Cold Ischemic Time - FYI only
Heart = 4-6 hours
Lungs = 4-6 hour
Liver = 8-12 hours
Pancreas = 8-12 hours
Intestine = 8 hours
Kidney = up to 72 hours in aggressive centers
Care of Transplant Recipient
Types of transplants
Autograft - from self
Isograft - from identical twin
Allograft - from another person
Xenograft - from animal
Recipient meds
needed to prevent rejection, critical to give to patients
also suppress immune system which
increases infection and cancer risk
calcineurin inhibitors
antiproliferative agents
mTOR inhibitor
steroids: prednisone
Types of rejection
acute rejection
may occur from weeks to months after transplant
all recipients have some amount of acute rejection
treatment
high dose steroids & more aggressive rejection drugs
T cytotoxic lymphocytes attack the transplanted tissue
chronic rejection
can take place over many years
the body's constant immune response slowly damages the transplanted tissues or organ
treatment
rejection drug adjustments
hyperacute rejection
occurs a few minutes after the transplant when the antigens are completely unmatched.
Ex: blood incompatibility
organ/tissue must be removed immediately to prevent death
treatment
organ/tissue removal and new transplant
Signs & symptoms of rejection
Pain at the site of the transplant
Feeling unwell fatigue/lack of energy
Flu -like symptoms
Organ specific indicators
ex. decrease UO & increase creatinine for renal
nursing
assess for rejection
monitor transplant organ/tissue function
prevent infection
high risk due to immunosuppression
hand hygiene, sterile dressing changes, assess for infection isolation precautions if on high doses of immunosuppressives
reliably administer meds to prevent rejection
collaborate with transplant team and nurse
pt and family teaching: meds, infection prevention, signs of rejection
cardinal signs of brain death
Coma or unresponsiveness - no eye opening or response to pain other than spinal reflexes
Absence of brainstem reflexes
pupillary reflex
ocular movement
oculocephalic reflex
oculovestibular reflex
corneal reflex
gag/oropharyngeal reflex
apnea
Apnea test
ventilated patient is disconnected from vent, supplemental 02 provided
goal is to stimulate resp center/breathing as CO2 builds
no observed resp effort = potential brain death
follow facility protocol
Death cannot be determined in these complicating conditions:
drug or alcohol induced state, hypothermia, shock, severe metabolic or electrolyte imbalances
Organ Procurement/Recovery Phase
surgery done in OR suite by transplant physicians
3-6 hours from start to finish
MTN coordinator with patient at all times tissue recovery to follow organ procurement family viewing is possible after procedure
donor is moved into the OR on the ventilator while heart is still beating. brain death supersedes (there is no cardiac death)
organ donation
Transplantable organs
heart, lungs, liver, kidneys, pancreas, small intestine
Transplantable tissues
bone, connective tissue (tendons, cartilage), vascular grafts (veins), heart valves, skin, eye tissue (globe of eye), corneas
living organ and tissue donations
kidney, part of the liver, intestine, lung or pancreatic, bone marrow, skin after certain surgeries such as an abdominoplasty, bone after knee and hip replacement umbilical cord blood, etc.
Rule of 100's - management goals for pt
SBP>100
Urine output>100
Pa02>100
Human Leukocyte Antigen (HLA) Testing
used primarily to test for compatibility in organ donation
prob going to need a lot of fluid to get them there. use pressors very sparingly
Missouri statute on death
"The occurrence of human death shall be determined in accordance with the usual and customary standards of medical practice, provided that death shall not be determined to have occurred unless the following minimal conditions have been met:
Cardiac death
When respiration and circulation are not artificially maintained, there is an irreversible cessation of spontaneous respiration and circulation, or
Brain Death:
When respiration and circulation are artificially maintained, and there is a total and irreversible cessation of all brain function, including the brain stem and that such determination is made by a licensed physician
cushing's triad because of herniation
definition different in every state
Brain death: How it happens
Brain injury/event causes cerebral edema, swelling in closed skull, herniation: swelling forces brainstem to shift down out of skull through foramen magnum, blood flow to brain stem and cerebellum is cut off, no blood flow = brain death
initial response is tachycardia, hypertension, vasoconstriction
can last minutes to hours
use beta blockers and vasodilators to prevent organs damage
once death/herniation occurs and sympathetic response "wears off' pts become hypotensive, bradycardic, cold, low cardiac output
use pacemakers, vasopressors, fluids to prevent organ damage
thyroxine, antidiuretic hormone, corticosteroid & insulin are also needed
organ procurement organization now coordinates care
focus in on maintaining heart (heart is tired/CO drops), lung (capillaries get leaky), and kidney (low perfusion) function that are critical to other organ functions
death is very stressful: try to keep them calm to save organs
all reflexes gone. absolutely nothing
Brain Death Testing
method is based on type of injury and age of patient
most pronouncements in adults are based on two sets of brain death tests
confirmatory test can reduce the time in between the 2 exams
brain death pronouncement is the patient's legal time of death
2 sets of tests are 6 hours apart
Notifying UNOS (United Network for Organ Sharing)
Once all organs are evaluated the coordinator calls UNOS:
Organs are placed locally first, then regionally, then nationally
Confirmatory tests
required in some cases, not in all
EEG
CBF (Cerebral Blood Flow) or CT angiography:
highly accurate, expensive
Transcranial doppler
acute kidney injury (AKI)
what is it
a spectrum of acute-onset kidney dysfunction
range =
mild impairment to acute renal failure (ARF)
Severe AKI
characterized by sudden decline in glomerular filtration rate (GFR) = oliguria
subsequent retention of products in the blood normally excreted by kidney
BUN increases
also called uremia or azotemia
disruption of electrolyte, acid-base, and fluid volume balances
Incidence
greater incidence in older patients (# of nephrons decline with age) & in those with preexisting chronic kidney disease
AKI in critically ill patient increases mortality rate to 38% to 80%
Most common causes:
Hypoperfusion
Nephrotoxins - NSAIDS, aminoglycosides, vancomycin, chemotherapy, immunosuppressants, poisons (ex. antifreeze), contrast dye, See pg. 1425 in textbook
at risk
underlying chronic kidney disease
sepsis - most common cause of AKI in critically ill
prevent by hydrating post test
stop other nephrotoxic medications if at risk
older age
heart failure
respiratory failure
trauma - rhabdomyolysis from crush injuries & burns
contrast-induced nephrotoxic injury - some agents less toxic
Types of AKI
prerenal AKI
any condition that decreases blood flow, blood pressure, or kidney perfusion before arterial blood reaches the renal artery that supplies the kidney
renal hypoperfusion (low CO, bleeding, vasodilation, thrombosis, etc.)
the most common cause of AKI (60-70% of cases)
Intrarenal AKI
any condition that produces an insult directly at the site of the nephron
prolonged ischemia: damage to tubules
toxic insult is related to substances that damage the renal tubular endothelium (antimicrobials, contrast dye)
burns and electrical injuries (rhabdomyolysis -> myoglobinuria -> kidney injury )
when internal filtering structures are affected= acute tubular necrosis (ATN)
damage to the kidney tubular epithelium. more severe AKI. Need dialisis
Postrenal AKI
any obstruction that hinders the flow of urine from beyond the kidney through the remainder of the urinary tract, ex. BPH, ureter strictures, catheter obstruction
not a common cause of AKI in the critically ill
hydronephrosis (kidney stones then pressure builds) enlarged prostate (back up)
A sudden onset of anuria should prompt nurse to check patency of catheter before assuming renal failure
Electrolyte Imbalances with AKI
hyperkalemia
restrict foods high in potassium
(potatoes, legumes, orange juice & prune juice, seafood, leafy greens, dairy)
monitor EKG
may lead to fatal dysrhythmia
tall peaked t-waves
widening QRS
leads to V-tach
will poop. if they don't give them more
prepare to administer
Insulin/glucose
forces potassium intracellularly
Diuretics
(furosemide) if producing urine
Sodium polystyrene (Kayexalate)
Routes include oral, Gl tube, or per rectum by enema
resin that binds with potassium
Dialysis: if k not changing
hyponatremia
because fluid overload
may not need to administer sodium, just fluid restrict fluids or dialyze
hypocalcemia
due to not being reabsorbed back in to the bloodstream at the proximal tubule and distal nephron and not being absorbed because Vit D not being activated
calcium level should be corrected for protein level
Chvosteks
ap on facial nerve and facial and eyelid muscles contract
Trousseau
carpopedal spasm when applying blood pressure cuff
may administer calcium replacements and phosphorous binding drugs
increase phosphate = decreased calcemia
hyperphosphatemia
due to not being excreted by the kidneys
may administer calcium salts (will raise calcium and lower phosphorous)
Phosphate binder with meals (ex. Sevelamer) when they eat
limit phosphorous intake- dairy products, processed meats, dark sodas, and nuts
stages
oliguric/anuric: decreased UO, lab values change
diuretic phase: increased UO obstruction in tubules clear
onset: period form insult until cell damage occurs
recovery: may or may not need dialysis
lab values
acidosis, BUN (waste) Cr (best meausre of kidney), creatinine clearace, uric acid
fluid overload
Abdominal trauma
management
frequent VS
assess lab values
serial Hbg/Hct needed to detect slow bleeds
prep for immediate surgery for acute abdomen, free air or fluid in abdomen or hemodynamic instability
send blood for type and crossmatch
provide 02 to keep Sp02 >92%
insert 2 large bore IVs (IOs if no blood)
control bleeding with pressure or tourniquet
-keep NPO if do not go to surgery
give broad spectrum antibiotics
Dx
nasogastric tube and urinary catheter look for
bleeding
serial laboratory tests (hgb/hct)
trends > single
CT scan of abdomen
only if hemodynamically stable
intra-abdominal pressures
if bedside ultrasound not available may use diagnostic peritoneal lavage (DPL)
negative for bleeding if solution returns clear
CXR
bedside ultrasound (FAST)
assessments
seatbelt sign
also assess for chance fracture (compress spine)
cullen's sign
bluish discoloration of the umbilicus
anterior abdomen injury
rebound tenderness
grey turner's sign
bruising of the flank
side abdomen injury
hard distended painful abdomen
acute abdomen
prep for
immediate exploratory laparotomy
kehr's sign
referred pain to the left shoulder
spleen injury
assess for
hemorrhage
sepsis
infection
organ specific injuries
liver
life threatening hemorrhaging
hemodynamically unstable
leads to
coagulopathies, acidosis, hyperthermia
spleen
sepsis
kehr's sign
life threatening hemorrhaging
intestinal injuries
sepsis and abscess or fistula formation
organ damage
hollow
increased infection
solid
increased bleeding
often associated with
multisystem trauma
pelvic fracture
assessment
lower limb paresis or hypoesthesia
hematuria
no pelvic rock
pelvic x ray show fracture
pain on palpation
CT or US will show fluid/blood in abdomen
perianal ecchymosis
coopernails sign
bruising of scrotum or labia
medical management
immediate surgery
stabilize pelvis by wrapping it (sheets or pelvic binder)
control bleeding
stabilize hemodynamics
nursing
assess for bleeding, neurovascular compromise
replace lost blood volume
borad spec abx
pain management
often associated with
life threatening hemorrhage
surgical management
internal or external fixation devices
complications
fat emboli
fatty bone marrow particles released into circulation will reach lungs
symptoms
respiratory distress, acute confusion, restlessness
treatment
call provider, place pt on non rebreather
hypothermia
management
remove wet/cold clothing
Continuously monitor
core
(rectal, bladder, esophagus, pulmonary artery cath) temperature
frequent VS monitoring
apply pacemaker if needed for symptomatic bradycardia
establish large gauge access
prepare to intubate if bradypnea or needed for rewarming
warm the pt
increase room temperature use overhead warmers or air blankets, warm IV fluids, warm o2
may due peritoneal, bladder, and stomach irrigation with warmed fluids
continuous cardiac monitoring
dx
metabolic acidosis or respiratory alkalosis
electrolytes
potassium initially hypo as rewarmed may become hyper
CBC
hemoconcentration of blood
Coags
inhibits coagulation management of hypothermia
glucose
may be increased or decreased
s/s
bradycardia (should check for pulse for at least 45-60 seconds)
bradypnea (may need to intubate)
apathy, poor judgment, dysarthria, ataxia, drowsiness, pulmonary edema, coma
what is it
core temperature less than 35° C (mild) to less than 28° C (severe)
risk factors
older age, younger age, chronic illness due to med effects, homelessness, substance use disorders, fatigue/sleep deprivation
other factors
time exposed, ambient temperature, submersion
hyperthermia
management
begin hydration may do oral fluids with electrolytes with heat exhaustion
IMMEDIATE intervention needed to prevent organ failure and death
IV with heat stroke (NS or LR)
monitor BP carefully for fluids shifts as temp lowers
reduce core temperature as fast as possible
how
remove clothing
relocate to cooler or shaded area if outside
place near fan or air conditioner
lower room temp
ice packs to groin & axilla
cooling blankets
continuously monitor core (rectal, bladder, esophagus, pulmonary artery cath) temperature
stop cooling at 38C or 100.4F
insert urinary catheter, monitor urine output for volume & rhabdo monitor for shivering (treat with benzodiazepines, meperidine, or neuromuscular blocking agents)
intubate and ventilate if needed
causes
heat exhaustion, heat illness, heat cramps, heat stroke
prevention
maintain hydration, use cooling centers, avoid activity in hot temps & between 10-1400, wear loose light clothes
risk factors
young and elderly due to inability for body to regulate temperature, athletes (or inactive trying to be an athlete), homelessness, medications (ex. diuretics, beta blockers, opioids), substance use disorders, environmental temp, time of day
heat exhaustion
(core temp 38°- 40° C)
body's thermoregulatory mechanism has failed; patient has lost sodium and fluid due to sweating
sweating profusely
may have level of consciousness changes & confusion other effects
tachycardic, tachypneic, and hypotensive
heat stroke
core temp greater than 40° C
body's thermoregulatory mechanism has failed;
red, dry skin;
no sweating
hypotension
tachycardia
other signs: confusion, delirium, seizures, lethargy; pulmonary edema, rhabdomyolysis; hypovolemic shock
Acute Pancreatitis
Complications
pancreatic necrosis (lead to MODS) (put it outside the body to protect other organs)
Pseudocysts (leak fluid)
Abdominal
compartment syndrome
cardiovascular:
hypovolemic shock (due to hemorrhaging and 3rd spacing)
renal:
acute renal failure
hematological:
disseminated intravascular coagulation
gastrointestinal:
GI bleed
septic shock
pulmonary:
ARDS, pleural effusions
ss
pain!!!!!!!!!
vomiting
nausea
fever
abdominal distention and gaurding
sings of hypovolemic shock (if severe)
due to fluid sequestrration in the abdominal cavity and or hemorrhaging (cullen and gray)
clay colored stool
care
Replace third spaced fluid
LR used for fluid replacement
colloids used if needed for low albumin level or anemia
Insulin?
depends on glucose levels
electrolyte replacement
calcium, magnesium, potassium pain management
NPO initially
absolutely nothing by mouth to let pancreas rest
EBP alert - new studies show enteral nutrition after first few days improves outcomes
nutrition can be given enterally if tube is in distal duodenum or jejunum or may need to be delivered parenterally
if pancreas is necrotic may need to be surgically removed
monitor patient for peritonitis and sepsis as well as symptoms of hemorrhaging proton pump inhibitors, anticholinergics/antispasmodics
PAIN! give them the good stuff
dx
CT scan/MRI
ultrasound
amylase levels elevated
lipase levels elevated
other labs affected
glucose- elevated due to damaged pancreas
calcium & magnesium- decreased due to
potassium- decreased (lost through vomiting)
Ranson Criteria
assess severity of acute pancreatitis and predict mortality.
0 to 2 points: Mortality 0% to 3% 0
3 to 4 points: 15%
5 to 6 points: 40%
7 to 11: nearly 100%
evaluate on admission or diagnosis
age more than 55 years
Leukocyte count more than 16.000 /mL
Serum glucose >200 mg/dL
Serum lactate dehydrogenase > 350 lU/mL
Serum AST > 250 IU/dL
evaluate during initial 48 hours
Fall in hematocrit > 10%
BUN level rise more than 5 mg/dL
Serum calcium less than 8 mg/dL
Base deficit > 4 mEq/L
Estimated fluid sequestration > 6L
Arterial Pa02 < 60 mmHg
2 most common causes
alcoholism (men)
gall stones (women)
Disseminated clotting
what is it
a complication of other serious life-threatening conditions
such as sepsis or delivery
may result in multiple organ failure and death
initial thrombotic stage characterized by
excessive clotting and consumption of clotting factors
fibrinolysis stage
clots break down increasing fibrin degradation products which are powerful anticoagulants and massive bleeding
s/s
bleeding from gums, venipunctures, and old surgical sites petechiae, purpura, bruising hemoptysis hematuria
subarachnoid hemorrhage
lab findings
CBC - decreased platelets, hgb, het
increased coagulant activity
PT increased
aPTT increased
D-Dimer increased
fibrinolytic activity
fibrin degradation product-increased
fibrinogen-decreased
medical management
maintain organ perfusion (prevent multiple organ dysfunction syndrome)
may need to place patient on oxygen or ventilator
intravenous fluids - NS or LR
inotropic agents
blood transfusions of red cells
platelet and fresh frozen platelets, & plasma transfusions
try to slow the consumption of coagulation factors heparin therapy - controversial
be able to calculate doses with nomogram
other treatments
recombinant human protein C
antithrombin Ill
treat metabolic acidosis associated with poor perfusion
Nursing
recognize and support vital physiologic functions
monitor for bleeding
frequent assessments of neurologic status, renal function, cardiopulmonary function, and skin integrity
Drowning
treatment
support cardiac and respiratory systems
may be intubated or receiving 100% via non rebreather
monitor for signs of pneumonia due to water inhalation
large number of these will progress to ARDS
may be hypothermic
targeted temperature management may be sued for neuroprotection
place in rescue position if breathing and no risk of SCI
initially may be tachycardic and hypertensive due to sympathetic nervous system, then may be hypotensive & bradycardic
what is it
drowning versus near drowning vs survival from drowning
risk factors
age, ability to swim, alcohol/drug use, trauma, rip tides, flooding, head trauma, substance use
may have water in lungs or lungs may be dry due to
bronchospasms
problems are caused by
hypoxia and may lead to
MODS and/or brain death
thoracic trauma
monitor for
dysrhythmias
caused by
cardiac contusions
oxygenation
caused by
pulmonary contusions
assess for
broken ribs
hemo/pneumo thorax
may need
intubate and ventilate
see resp notes
Acute Tubular Necrosis
what is it
nephrotoxic or ischemic injury damages kidney tubular epithelium
used to describe severe Al and ARF that requires hemodialysis
damage prevents normal concentration of urine, filtration of wastes, and regulation of acid-base, electrolyte, and water balance
Phases of ATN/AKI
Onset/Initiating phase
period from the insult until cell injury occurs
lasts hours to days depending on compensatory mechanisms
Oliguric/anuric phase
decreased output means damage has been done down to basement membrane
May last up to two weeks
GFR is reduced
elevated BUN and Cr,
electrolyte abnormalities and metabolic acidosis may develop
Diuretic phase
some pts have this, not everyone
characterized by an increase in the GFR and sometimes by polyuria
kidneys can clear fluid volume but not solutes
Recovery Phase
kidney tubular cells that have survived proliferate
kidney function slowly returns to normal with a GFR that is 70-80% of normal within 1-2 years
if severe kidney damage was done the BUN and Cr levels may never return to normal - some may require lifelong dialysis
labs
metabolic acidosis - due to accumulation of un-excreted waste products
BUN - affected by hydration, catabolism, GI bleed, infection, fever, steroids, nutrition
BUN, creatinine, uric acid, phosphorous, potassium, and magnesium will be elevated in AKI
creatinine clearance - most reliable estimation of GFR
Most accurate method requires 24 hr urine collection
metabolism (different values for men/women & age)
serum creatinine - most reliable indicator of renal function: by product of muscle
Other assessments
Hemodynamic monitoring
preload (CVP) measurements helpful to assess volume status
3rd spacing- may gain weight but be intravascularly dry
Renal Replacement Therapy: Dialysis
Hemodialysis
separates and removes from the blood the excess electrolytes, fluids, and toxins
hemodialyzer- "artificial kidney"
traditional hemodialysis completed over 3-4 hours
must be stable
Continuous Renal Replacement Therapy (CRRT) & Sustained Low Efficiency Dialysis (SLED)
Used for
critically ill patients who may not be able to tolerate a rapid shift of fluids
Anticoagulation
required to keep blood from clotting in machines
heparin or trisodium citrate
for heparin - monitor aPTT
for trisodium citrate - monitor ionized calcium (put on calcium drip with it)
Safety Alert: must have Ca+ chloride infusing as well as trisodium citrate because citrate binds with calcium in dialyzer to prevent clotting
Principles of dialysis
fluid removal
Osmosis (concentration of blood > dialisate)
hydrostatic pressure
Ultrafiltration
solute removal
Diffusion
Convection
timing
CRRT done over 24 hours or more (constant kidney)
SLED completed over 6-12 hours
Vascular Access
temporary=venous access in large vein
longterm
fistula
Permacath
tunneled central dialysis access
arteriovenous graft - artificial tube used to connect artery to vein
Assess patency of fistulas/grafts: feel the thrill, hear the bruit
arteriovenous fistula - artery and vein joined
have to be able to take care of it at home
Care of fistulas/grafts
limb alert, assess distal perfusion, to be used for dialysis only
thrill and brue
complications
exsanguination infection
electrolyte imbalances
clots
air embolism
fatigue, muscle cramps, nausea, dizziness, HA hypoglycemia
hypotension
acid base imbalances
nursing
assess for complications assess
monitor BP
monitor labs carefully (electrolytes, Hbg, BUN/creatinine)
ensure dietary restrictions & needs are met
daily weights
access site for bleeding
collaborate with pharmacy and dialysis nurses to determine whether to give or hold meds before dialysis
anticipate fatigue after dialysis, provide cares before
check glucose afterward, especially if diabetic
teaching: nutrition, access care, daily weights, complications
Peritoneal dialysis
able to complete at home
usually not started in the ICU but patient may come in with PD catheter
Patient/family must be able to understand and perform sterile technique
Complications
peritonitis - abdominal pain/rigidity, cloudy effluent (return drainage)
insertion site infection
prevent by using sterile technique to make tubing connections & patient & nurse are masked while catheter is open to air
takes fluid and solutes off over a longer period of time than hemodialysis
requires several fluid exchanges in a day
removes electrolytes (especially K thats unresponsive to everything)
does the work of the kidney, doesn't fix it
may or may not need it forever
Poisoning
medications and antidotes
medication
antidote
opioids
naloxone
benzos
flumazenil
warfarin
vit k
heparin
protamine sulfate
beta blockers
glucagon
calcium channel blockers
calcium chloride
acetaminophen
acetylcysteine
insulin
glucose and glucagon
contact poison control
consider antidotes
activated charcoal
facial fratures
management
may need to have jaws wired shut
keep wire cutters WITH pt at ALL times
appropriate diet
surgery to align and fixate
HOB elevated
control bleed
get IV access
monitor CSF leak
airway #1
emergency tach
complications
respiratory difficulty
primary concern
stridor
dyspnea
tachypnea
hypoxia
hemorrhage
watch if they are swallowing a lot
infections due to
flora in mouth and potential CSF leak
broad spec abx
CSF leak
vision loss
increased ICP
LeFort fractures
fractures to the maxillary bones
grades
speak no evil, see no evil, hear no evil
Acute Gastrointestinal Hemorrhage
what is it
bleeding in the upper or lower Gl tract
Upper Gl Bleeds
PUD - peptic ulcer disease
esophagogastric varices
distended blood vessels of the esophagus and proximal stomach develop as a result of portal hypertension
Lower GI Bleeds
Hemorrhoids
Inflammatory Bowel Disease: ulcerative colitis, Crohn's
Diverticulitis/Diverticulosis
Tumors and Polyps
dx
visual of blood in vomit/stool
+Guaiac of emesis or stool
endoscopic studies to look for source of bleeding - EGD or colonoscopy
serial Hab/Hct
treatment
treat underlying cause monitor I/O
monitor vital signs frequently
NG tube: low intermittent suction control bleeding
Banding/Clipping
Give antidote if on anticoagulant
Airway & Oxygen
Blakemore Tube can be placed to put pressure on varices until patient is more stable
tube not left in for more than 24 hours
keep scissors at bedside due to potential respiratory difficulties
may have to sedate patient while tube is in place
deflate one balloon at a time
begin 2 large bore IVs send for blood type and crossmatch
administer blood products as ordered
vasopressin
reduces mesenteric blood flow
octreotide
slows down motility, increases water absorption, reduces variceal blood flow and reduces variceal pressure
anemia
due to
decreased erythropoietin produced by kidneys
problem occurs with chronic kidney disease, not acute
OR
if hgb increases above 12 gm/dL call provider- may hold or dc
may give erythropoietin SC or IM g wk or month
monitor hemoglobin and blood pressure (may cause HTN)
if hgb increases by more than 1 gm/dL in a 2 week period
RENAL BABY YEAHHHH
