Rosen & Barkin's 5-Minute Emergency Medicine Consult (208 page)

• Check airway, breathing, and circulation.
  
• Vascular access related:
  
  • Bleeding:
    
    • Firm pressure to site(s)
      
    • Do not totally occlude access; may cause clotting.
      
    • Will likely need pressure applied for at least 5–10 min to stop even minor bleeding
      
    • Document presence or absence of thrill after pressure was applied.
      
    • Apply Gelfoam.
      
• Nonvascular access related:
  
  • Hypotension:
    
    • Search for underlying cause.
      
    • Vasopressors, fluids
      
  • Shortness of breath:
    
    • Preload and afterload reduction with nitrites and ACE inhibitors.
      
    • Attempt diuresis if fluid overload is suspected cause.
      
    • Arrange for dialysis.
      
  • Hyperkalemia:
    
    • Administer IV calcium, bicarbonate, insulin, and glucose when appropriate (see “Hyperkalemia”).
      
    • Monitor cardiac rhythm.
      
    • Administer ion-exchange resin (Kayexalate).
      
    • Arrange for dialysis.
      
  • Neurologic complications:
    
    • Administer naloxone, thiamine, dextrose (or Accu-Chek) for altered mental status.
      
    • Control seizures with benzodiazepines.
      

• Vascular access related:
  
  • Infection:
    
    • Initiate antistaphylococcal IV antibiotics.
      
  • Clotted access:
    
    • Analgesia
      
    • Warm compresses
      
    • Vascular surgery consult
      
  • Hemorrhage:
    
    • Control bleeding.
      
    • Correct coagulopathies.
      
    • Administer IV fluids and blood products.
      
• Nonvascular access related:
  
  • Electrolyte imbalances:
    
    • Treat hypercalcemia or hypermagnesemia with saline infusion if tolerated (dilution).
      
    • Diuresis with furosemide after preload and afterload reduction (nitroglycerin, enalapril)
      
    • Arrange for dialysis.
      
  • Volume overload:
    
    • Attempt diuresis with nitrites and furosemide.
      
    • Arrange for dialysis.
      
  • Pericardial effusion or tamponade:
    
    • Emergent pericardiocentesis may be necessary in unstable patient.
      
    • Arrange for dialysis.
      
  • Acute MI:
    
    • Thrombolytics or angioplasty if patient is appropriate candidate
      
    • Nitrates to decrease myocardial workload
      
  • Disequilibrium syndrome:
    
    • Rule out other causes of altered mental status.
      
    • Generally resolves over time
      
• Peritoneal:
  
  • Peritonitis: IV or intraperitoneal antibiotics
    
  • Culture catheter or tunnel infection, visible exudates:
    
    • Oral antibiotics (antistaphylococcal)
      
    • If recurrent or tunnel, may need to be unroofed
      
    • Meticulous site care
      
  • Perforated viscous:
    
    • IV antibiotics
      
    • Surgical consultation
      

• Calcium gluconate: 1 g slowly IV (cardioprotective in hyperkalemia with widened QRS complex)
  
• Cefazolin: 1 g IV or IM followed by 250 mg/2 L bag for 10 days (peritonitis)
  
• Captopril: 25 mg sublingually
  
• Dextrose D
  ₅₀
  W: 1 amp: 50 mL or 25 g (peds: dextrose D
  ₂₅
  W: 2–4 mL/kg)IV
  
• Dopamine: 2–20 μg/kg/min IV
  
• Enalapril: 1.25 mg IV
  
• Furosemide: 20–100 mg IV (may require doses of ≥30 mg to effect diuresis in chronic renal failure)
  
• Insulin: 5–10 U regular insulin IV (with D
  ₅₀
  for hyperkalemia)
  
• Naloxone (Narcan): 2 mg (peds: 0.1 mg/kg) IV or IM initial dose
  
• Nitroglycerin: 0.4 mg sublingually; 5–20 μg/min IV
  
• Sodium bicarbonate: 1 mEq/kg up to 50–100 mEq IV PRN
  
• Sodium polystyrene sulfonate (Kayexalate): 1 g/kg up to 15–60 g PO or 30–50 g retention enema q6h PRN (for hyperkalemia)
  
• Thiamine (vitamin B
  ₁
  ): 100 mg (peds: 50 mg) IV or IM
  
• Tobramycin: 1.7 mg/kg IV or IM followed by 10 mg/2 L bag for 10 days (peritonitis)
  
• Vancomycin: 1 g IV or IM followed by 50 mg/2 L bag for 10 days (peritonitis)
  

FOLLOW-UP

• ICU admission:
  
  • Severe hyperkalemia
    
  • Pulmonary edema
    
  • Volume overload
    
  • Persistent hypotension
    
  • Uncontrolled seizures
    
  • Acute MI
    
  • Cardiovascular accident
    
  • Pericarditis
    
  • Sepsis
    
  • Peritonitis with toxic or systemic symptoms
    
• Regular admission:
  
  • Fever
    
  • Vomiting
    
  • Peritonitis without toxic or systemic symptoms
    
  • Non–life-threatening electrolyte disturbances
    
  • Inability to provide self-care for continuous ambulatory peritoneal dialysis with antibiotics
    

• Mild infections of access site
  
• Same-day surgery for some thrombectomy procedures
  
• Hemostasis at puncture sites
  

Most patients on dialysis are followed closely by their nephrologists.

• Consider cardiac tamponade in dialysis patients, even when they don’t exhibit classic symptoms.
  
• Always consider hyperkalemia in dialysis patients.
  
• Infections can have very subtle presentations in dialysis patients and are a common cause of morbidity and mortality
  
• Early vascular surgery consultation is important for patients with clotted or ruptured access sites
  

• Feldman HI, Held PJ, Hutchinson JT, et al. Hemodialysis vascular access morbidity in the United States.
  Kidney Int
  . 1993;43(5):1091–1096.
  
• Khan IH, Catto GR. Long-term complications of dialysis: Infection.
  Kidney Int Suppl
  . 1993;41:S143–S148.
  
• Zink JN, Netzley R, Erzurum V, et al. Complications of endovascular grafts in the treatment of pseudoaneurysms and stenoses in arteriovenous access.
  J Vasc Surg.
  2013;57:144–148.
  
• Padberg FT Jr, Calligaro KD, Sidawy AN. Complications of arteriovenous hemodialysis access: Recognition and management.
  J Vasc Surg
  . 2008;48:55S–80S.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Renal Failure
  
• Hyperkalemia
  

CODES

• 996.1 Mechanical complication of other vascular device, implant, and graft
  
• 996.62 Infection and inflammatory reaction due to other vascular device, implant, and graft
  
• 999.9 Other and unspecified complications of medical care, not elsewhere classified
  

BASICS

• Very common dermatologic disorder of infancy
  
• Most common in 1st month of life and again at 12–24 mo
  
• Incidence in adult incontinent patients is reported from 5.7% to more than 42% and appears to be strongly associated with age
  
• Primary irritant/contact dermatitis:
  
  • Outer skin layers are broken down, leading to inflammation, impairment of normal skin microflora, and loss of protective barrier function.
    
  • Increased skin moisture encourages growth of microorganisms on the surface of the skin.
    
  • Secondary fungal or bacterial infection can cause more severe forms of diaper dermatitis.
    
• Also known as irritant diaper dermatitis
  

• Irritants:
  
  • Moisture:
    
    • Prolonged overhydration owing to infrequent diaper changes, poorly absorbing diapers or cloth diapers, urinary or faecal incontinence in adults
      
  • Friction:
    
    • Diaper rubbing on skin or loose-fitting diaper
      
  • Chemicals:
    
    • Prolonged exposure to stool enzymes and urine
      
    • Scents or moisturizers in wipes or soap
      
    • Diaper material or adhesive used to hold diaper in place
      
• Infection:
  
  • Candida albicans
    :
    
    • Isolated in up to 80% of infants
      
    • Overgrowth common after systemic antibiotic use
      
  • Bacterial
    
  • Often complication of other causes of dermatitis:
    
    • Staphylococcus aureus, Streptococcus, Escherichia coli
      are common;
      Peptostreptococcus
      and
      Bacteroides
      may also be encountered.
      
• Seborrheic diaper dermatitis
  
• Atopic diaper dermatitis (contact dermatitis)
  
• Risk factors:
  
  • Oral thrush
    
  • Number of previous episodes of diaper rash
    
  • Duration of use of diapers
    
  • Diarrhea