14.6 Genitourinary, Renal & Dialysis Emergencies

14.6 Genitourinary, Renal & Dialysis Emergencies

CPCF Appendix A foundational knowledge #2 and #4 require the PCP to understand genitourinary structure and function — blood filtration, kidney function, and elimination of waste — and the pathology that follows when it fails. Patients receiving dialysis are among the most physiologically fragile people paramedics transport, and they present with a recognizable and examinable set of emergencies.

What the Kidney Does, and What Happens When It Stops

Hyperkalaemia: The Emergency to Recognize on the Monitor

Hyperkalaemia is the single most examinable renal emergency because it is lethal, common, and visible on a rhythm strip. Typical triggers are a missed dialysis session, a blocked or failing access, crush injury or rhabdomyolysis, extensive burns, acidosis, and potassium-sparing drugs such as ACE inhibitors, angiotensin receptor blockers, and spironolactone.

The ECG progression, in order:

1. Tall, narrow, peaked T waves — often the earliest change, best seen in the precordial leads
2. Flattened or absent P waves, with PR prolongation
3. Progressive QRS widening
4. Sine wave pattern as the widened QRS merges with the T wave
5. Ventricular fibrillation or asystole

Clinically the patient may report muscle weakness, cramps, paraesthesia, and palpitations, and may be profoundly bradycardic.

[!CAUTION] A dialysis patient who has missed a session and presents with bradycardia, a wide QRS, or peaked T waves is a cardiac arrest in progress. Treat this as a time-critical transport, notify the receiving facility early so that the dialysis team can be mobilized, and manage the rhythm within your directive. Definitive treatment is dialysis.

The Missed Dialysis Session

Missed dialysis produces a predictable triad, and the presenting complaint depends on which part dominates:

1. Fluid overload — dyspnoea, orthopnoea, crackles, frank pulmonary oedema, hypertension. Sit the patient up, give oxygen, and consider CPAP within your directive; these patients often respond dramatically to positive airway pressure. Be cautious with nitrates if the patient is preload-dependent or hypotensive.
2. Hyperkalaemia — as above.
3. Uraemia — nausea, vomiting, confusion, pruritus, pericarditis with a friction rub and pleuritic chest pain.

Ask when the last dialysis session was, how much weight they usually have removed, and whether the session was completed or cut short. This is the highest-value history in the entire call.

Dialysis Access: Do Not Damage It

Bleeding from a fistula after needle removal can be life-threatening because of the arterial pressure and the platelet dysfunction of uraemia. Apply firm, direct, localized pressure over the puncture site — enough to stop bleeding but not so much that the thrill is abolished — and do not apply a circumferential tourniquet.

Complications During or Immediately After Dialysis

• Hypotension — the most common complication, from excessive or rapid fluid removal. Lie flat, elevate legs, and treat within scope.
• Disequilibrium syndrome — rapid urea clearance causes cerebral oedema; headache, nausea, confusion, and rarely seizures, typically toward the end of or just after a session.
• Air embolism — sudden dyspnoea, chest pain, and collapse during dialysis. Place the patient left lateral and head down, give high-concentration oxygen, and transport urgently.
• Haemolysis, pyrogenic reactions, and anaphylaxis to the circuit are less common but present as acute collapse during treatment.

Other Genitourinary Emergencies

Urinary retention — inability to void with a distended, tender, palpable bladder that is often exquisitely painful. Common causes: prostatic enlargement, anticholinergic and opioid medications, constipation, urinary tract infection, post-operative state, and neurological disease. In a patient with a spinal cord injury at or above T6 it is a leading trigger of autonomic dysreflexia (Section 16.4). Relief of retention is the treatment; catheterization falls under CPCF skill #28 where authorized.

Blocked urinary catheter — a patient with a catheter who is not draining, is agitated, is in pain, or is autonomically dysreflexic has a blocked catheter until proven otherwise. Check for kinks, a full drainage bag, a bag positioned above the bladder, constipation, and tube compression before anything else.

Urinary tract infection and urosepsis — in older adults, a urinary tract infection may present with delirium, falls, or functional decline and no urinary symptoms at all. Do not dismiss new confusion as dementia. Urosepsis is the commonest source of sepsis in older adults and carries high mortality; look for the physiological signs rather than for dysuria.

Renal colic — sudden severe loin-to-groin pain, patient restless and unable to stay still, with nausea, vomiting, and haematuria. The critical exclusion in an older patient is ruptured abdominal aortic aneurysm, which mimics renal colic closely and kills quickly; first-presentation "renal colic" over the age of 50 deserves that consideration explicitly.

Testicular torsion — sudden severe testicular pain, often with nausea and vomiting, in an adolescent or young adult, with a high-riding testis and absent cremasteric reflex. It is a time-critical surgical emergency with a salvage window of roughly six hours. Do not dismiss abdominal or groin pain in a male patient without asking directly.

Priapism — a sustained painful erection, associated with sickle cell disease, some medications, and spinal cord injury, is a urological emergency and a source of considerable embarrassment; ask and document matter-of-factly.

Assessment and Management Priorities

1. Dialysis history first in any known renal patient: last session, completed or shortened, usual dry weight, access type and location, and the schedule.
2. ECG in any renal patient with weakness, palpitations, bradycardia, or a missed session — you are looking for hyperkalaemia.
3. Protect the access limb and document the presence or absence of a thrill and bruit.
4. Be conservative with fluids in dialysis-dependent patients; volume that helps a normal patient can precipitate pulmonary oedema here.
5. Adjust medication expectations — renally cleared drugs accumulate, and standard doses may behave as overdoses.
6. Remember the baseline anaemia. A haemoglobin that is low at baseline means less reserve for any additional blood loss.