Renal

Emergency
Helena Tridasari N
M Febryan Kevien F
Jacinda Risha O

Supervisor : Ali Haedar, MD, Sp.EM, FAHA

 RENAL FAILURE
Chronic kidney disease:
A spectrum of different pathophysiologic processes
associated with abnormal kidney function and a
progressive decline in glomerular filtration rate

Structural kidney damage or decreased kidney

function [decreased glomerular filtration rate
(GFR)] for > 3 months

End-Stage Renal Disease (ESRD):

GFR less than 15ml/min per 1.73m, accompanied in
most cases by uraemia, or a need to start kidney
replacement therapy (dialysis or transplantation).

Bargman, J.M., Skorecki, K. 2012. Harrison’s Principles of Internal Medicine.

Mc-Graw Hill Publication
Ho, K., Manning, P. 2015. Guide to the Essentials in
Emergency Medicine. Mc-Graw Hill
Risk Factors

Bargman, J.M., Skorecki, K. 2012. Harrison’s Principles of Internal Medicine.

Mc-Graw Hill Publication
 Pathophysiology

Nephron destroyes Thickening Futher damage of

glomerular vessels nephrons

Start End
CKD

Chronic Kidney
Disease

Iniating mechanism Nephron Glomerular

by risk factors hypertrophy sclerosis

Bargman, J.M., Skorecki, K. 2012. Harrison’s Principles of Internal Medicine. Mc-Graw Hill Publication
Bargman, J.M., Skorecki, K. 2012. Harrison’s Principles of Internal Medicine. Mc-Graw Hill Publication
Your Picture Here

Classification of
Chronic Kidney
Disease
 Clinical Features
Hypertension

Uremia – nausea/vomitting, Metabolic acidosis

percarditis, encephalopathy,
neuropathy

Hyperphosphatemia and
Pruritis, easy bruisability Contents Title
You can simply
hypocalcemia
impress your
audience.

Fluid overload, edema,

Hyperkalemia - arrythmia pulmonary edema

Anemia, due to erythropoietin

deficiency
Suwitra K. Penyakit Ginjal Kronik. In: Sudoyo AW, Setiyohadi B, Alwi I, et al.,
3rd ed. Buku Ajar Ilmu Penyakit Dalam. Jakarta: InternaPublishing 2009:1035-1040
Treatment
Renal Emergency
 Hyperkalemia

Chong, Jack. F. C, 2017. accessed in https://www.emnote.org/emnotes/treating-hyperkalemia on Februari 2nd, 2019

 Pulmonary Oedem

Algoritma manajemen edema/kongesti paru akut. (ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure, 2012)
 Fluid Overload
 Drug therapy  Non Drug therapy
 GTN 0,5 mg  Place patient in an upright position
sublingually (SL) or  Administer high flow oxygen
nitroderm patch 5-10  Monitor ECG, vital sign, pulse oximetry
mg or IV 10-200 ug/min
 Preserve one upper limb vessel for
 Morphine 2-5 mg IV
(severe pulmonary future arteriovenous access (no blood
oedema) taking or drip setting)
 Felodipine 2.5 mg PO if  Draw blood complete blood count, Ur/Cr,
the blood pressure is electrolytes, and arterial blood gas,
high cardiac enzyme tests if cardiac ischemia
 Furosemide 120-240 is suspected
mg IV

Ho, K., Manning, P. 2015. Guide to the Essentials in Emergency Medicine. Mc-Graw Hill
Renal Replacement Therapy
6 Case
Jan
Report
Patient with Renal
Emergency
Admitted in Saiful Anwar General Hospital
Patient Identity
Name Sex Date of Birth
Mrs H Female 1st July, 1961

Address Religion Reg No.

Panggungrejo Moeslem 139xxxxx
Pasuruan

Marriage Assurance
Married JKN
Primary Survey
A Airway
Patent , Stridor (-) , Wheezing (-) , Ronchi (+) all area,
Gargling (-)

B Breathing
RR 30x / min, regular, SpO2 98% on NRBM 10 lpm, Intercostal
Retraction (-)

C Circulation
Pulse 106/min, regular , strong, TD : 180/90 mmHg, warm ,CRT
<2 second

D Disability
GCS 456 , Pupil isokor ø 3m/3m ,RC +/+

E Environment
Tax : 37 C , Pitting edem +/+ in lower and upper extremity
 Primary Intervention

A B C D E

Airway Circulation Environment

Semifowler IVFD NaCl 0,9% Give Blanket
position 30º Maintenance 10
Breathing dpm , Catheter Disability
Oxygen NRBM urine Insertion Vital sign
10 lpm Monitoring
Place Your Picture Here

Anamnesis
Chief Complaint
Shortness of Breath

History of Present Illness

Patient come to ER RSSA with chief complaint
shortness of breath. She complaint about shortness of
breath since 2 days before admission and getting worse
since 1 days. Shortness of breath is mainly triggered by
activities ,such as walk around 100meter, sweeping and
take a bath. She felt shortness of breath especially she
was feeling tired and relived by rest. She cannot sleep
in a flat position. She also complaint about cough since
1 week with white sputum.
She also has Hypertension after he has been
diagnose with CKD. The higher tension she has ever
had 200/… He does routinely look for medication for
hypertension. She diagnosed with CKD since 4 years
ago and rountine HD. Fever (-), nausea (-), vomiting (-).
Place Your Picture Here

Past Medical History

She had been Hospitalized 2 times ,last times in
8 month ago with same complain shortness of
breath.

Social History
Patient is a Housewife, have 3 children, married.
Alcohol consumsion (-), herbal medicine (+) since
she 30 years old, softdrink (-).

Family History
Her family don’t have same problem as her.
 PhysicalExamination
General Appearance: looked moderately ill Looked normoweight BMI : 26,6

HR : 106 bpm regular

GCS: 456 180/90 mmHg RR : 30 tpm Tax : 37 °C
strong
Head Anemic conjunctiva (+) icteric sclerae (-).
Neck JVP: R + 5 cm H2O in 30° position Lymphonode enlargement -
Wall Chest expansion symmetric

Chest Ictus invisible, palpable ICS V 3 cm lateral MCL S Trill: - Heaves: -

Heart RHM ~ SL D LHM ~ ictus
S1 and S2 single, no murmur

Stem Fremitus D=S S S v v Rh + + Wh - -

SS v v + + - -
Lung
SS v v + + - -
Percussion : dullness at basal lung dextra and sinistra

flat, bowel sound normal, epigastrial tenderness (-), liver span 8 cm, Traube’s space
tympani
Extremities Warm, pitting edema (+) in lower and upper extremity
 Planning
Diagnose
Insert Your Images Insert Your Images

Laboratory Radiology

CBC  Chest X-Ray

Electrolyte Serum
Ureum/Creatinin
ALT/AST
Blood Gas Analysis
 LaboratoryFindings
Lab Value Normal Lab Value Normal
Hb 6,10 g/dL 11,4 – 15,1 AST 78 U/L 0-32
RBC 2,02 106 4,5 – 5,0 ALT 56 U/L 0-33
/µL
WBC 7,24 103/µL 4,7 – 11,3 Ureum 161,00mg/ 16,6 – 48,5
dL
HCT 15,80% 38 - 42 Creatinin 14,30mg/d <1,2
L
PLT 173 103/µL 142 – 424 Natrium 137 136-145
mmol/L
GDS 116 mg/dL < 200 Calium 4,45 3,5-5,0
mmol/L
Clorida 100 98-106
mmol/L
 LaboratoryFindings

Lab BGA Value

Ph 7.27 7.35-7.45
PCO2 25.9 35-45 mmHg
PO2 86.0 80-100 mmHG
HCO3 11.9 21-28 mmol/L
BE -15,2 -3 UNTIL +3
Sp02 99% >95%
Conclusion Metabolic Acidosis
 ChestX-Ray

Conclusion
Pleural Effusion
Pulmonary Edema
 Shortness of Brearh
01 dt Chronic Kidney Disease stage V

Working Diagnose
Mrs. H | 139xxxxx | 1st July, 1961
02 Acute Lung Oedem
 Treatment

Head up 30o Oxygen NRBM IVFD NS 0,9%

10 lpm 20 dpm

CKD and ALO

IV Furosemide IV Lansoprazole
40-0-0 mg 30mg
Discussion
Renal Emergency
 Case Theory
She also has Hypertension after he has
been diagnose with CKD. The higher tension
she has ever had 200/… He does routinely
look for medication for hypertension. She
diagnosed with CKD since 4 years ago and
rountine HD. Fever (-), nausea (-), vomiting
(-).
Case
• Hypertension 180/90
mmHg (examination)
• Metabolic Acidosis (laboratory)
• Shortness of Breath (chief
complain)
• Pleural Effusion (xray)
• Pulmonary Edema (xray)
• Rhonki +/+ (examination)
• RR 30x/minute (examination)
•
Pitting edema (examintaion)
• Hb 6,10 (lab)
Theory
• Hypertension
• Metabolic acidosis
• hyperphosphatemia and hypocalcemia
• Fluid overload, edema, and pulmonary edema
• Anemia, due to erythropoletin deficiency
• Hypercalemia – arrythmia
• Pruritis
• Uremia – nausea/vomiting,
• Pericarditis
• Ancephalopathy
• neuropathy
 Pulmonary oedem
Case
therapy
• Head up 30
• O2 NRBRM 10 lpm
• IVFD 0.9% 20 dpm
• IV furosemide 40mg – 0 – 0
• IV lansoprazole 30 mg
 Case Fluid Overload
• Head up 30 Drug therapy Non drug therapy
• O2 NRBRM 10 lpm • GTN • Upright posistion
• IVFD 0.9% 20 dpm • Morphine • High flow oxygen
• IV furosemide 40mg – 0 – 0 • Felodipine • Monitor ECG, Vital sign,
• IV lansoprazole 30 mg • Furosemide 120-240 pulse oximetry
mg • Preserve one upper limb
vessel
• Draw blood complete
blood count, Ur/Cr,
electrolite, and cardiac
enzyme
Lesson learn

• How to assess patient with CKD

• How to look for CKD’s complication in patient with CKD

• How to treat CKD’s Complications in patient with CKD

Thank You
2019 | Renal Emergency