Transcript Chapter 21: Genitourinary and Emergencies

Chapter 21
Genitourinary and
Renal Emergencies
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaint.
National EMS Education
Standard Competencies
Genitourinary/Renal
• Blood pressure assessment in hemodialysis
patients
• Anatomy, physiology, pathophysiology,
assessment, and management of
• Complications related to:
− Renal dialysis
− Urinary catheter management (not insertion)
• Kidney stones
National EMS Education
Standard Competencies
Genitourinary/Renal (cont’d)
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of
• Complications of:
− Acute renal failure
− Chronic renal failure
− Dialysis
National EMS Education
Standard Competencies
Genitourinary/Renal (cont’d)
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management
of
− Renal calculi
− Acid/base disturbances
− Fluid and electrolytes
− Infection
− Male genital tract conditions
Introduction
• The urinary system
− Balances the levels of electrolytes, water, acids,
and bases in the blood
− Removes metabolic wastes, drug metabolites,
and excess fluids from the blood
Introduction
• Types of renal disorder:
− Kidney disease
− Renal calculi
− Urinary tract infection
− Noncancerous enlargement of the prostate
Anatomy and Physiology
Kidneys
• Located in the
retroperitoneal
space
• Composed of:
− Hilus
− Three outer layers
− Three internal
parts
© Jones & Bartlett Learning
− Calyces
Kidneys
• Ureters transport urine from the kidneys to
the bladder.
• One fourth of the body’s systemic cardiac
output flows through the kidney each
minute.
Kidneys
• Nephrons
− In the cortex
− Structural and functional units that form urine
Kidneys
Kidneys
• Glomerular capsule
− Double-layered cup
• Podocytes
− Form filtration slits
• Blood moves from the
afferent arteriole into the
capillaries of the
glomerulus.
− Pressure increases.
Kidneys
• The filtrate initially contains everything that
can pass through the filtration membrane.
− As filtrate passes through the rest of the
nephron, it is converted to urine.
• Additional reabsorption of water and
electrolytes occurs in the loop of Henle.
Kidneys
• After leaving the loop of Henle, the fluid
enters the DCT.
• The juxtaglomerular apparatus is formed
where the efferent arteriole meets the DCT.
• ADH and aldosterone control the final
adjustments to the composition of urine.
Kidneys
• Neurons in the hypothalamus monitor the
solute concentration of the blood.
− Aldosterone plays an active role in reabsorption.
• Diuretics increase urinary output.
− Work in a variety of ways
Ureters
• Urine:
− Enters the collecting ducts
− Passes through the calyces
− Goes to the renal pelvis
− Moves through the ureters
Urinary Bladder
• Collapses when empty
• Expands when full
• The brain controls the urge to void.
− External urinary sphincter remains contracted
until conditions are favorable
Urethra
• Part of the lower
urinary tract
• Expels urine
• Male urethra is
divided into three
regions.
Scene Size-Up
• Take standard precautions to avoid contact
with urine.
• Renal problems may mimic other abdominal
problems.
− It may be difficult to identify the source of pain.
Primary Assessment
• Form a general impression
− Patient may exhibit extremes of activity
• Airway and breathing
• Circulation
• Transport decision
− Consider how the patient will be moved.
History Taking
• History and physical exam
− Provide the necessary information for patient
management
• Eighty percent of all medical diagnoses are
based on the patient's history.
Secondary Assessment
Four quadrants
(internal organs)
Nine anatomic segments
Reassessment
• Electrolyte imbalances can cause rapid
deterioration in the functioning of organs.
• Form a treatment plan.
• Take serial vital signs at least every
5 minutes in patients with possible renal
failure.
Pathophysiology, Assessment, and
Management of Specific Emergencies
• Range from mild to
true emergencies
• Prehospital care is
usually supportive.
− Recognizing the
condition helps provide
a positive outcome.
• Many of these
conditions cause
urinary retention.
Pain
• Pathophysiology
− Pain may be:
• Visceral
• Referred
• Assessment
− Use OPQRST to evaluate type and severity
Pain
• Management
− After assessing ABCs, allow patient to assume
a position of comfort.
− Be prepared for potential nausea and vomiting.
− Provide analgesia if necessary.
− Establish an IV line.
Urinary Tract Infections (UTIs)
• Definitive treatment requires antibiotics.
• Pathophysiology
− Usually develop in lower urinary tract
• Spread if untreated
Urinary Tract Infections (UTIs)
• Classic symptoms:
− Painful urination
− Frequent urges to
urinate
− Difficulty urinating
− Pain
• Patients appear
restless and
uncomfortable.
• Vital signs vary based
on degree of illness.
Urinary Tract Infections (UTIs)
• Management
− Mainly supportive care of ABCs
− Transport in a position of comfort
− Be prepared for nausea or vomiting.
− Analgesics in severe cases only
− Establish an IV line.
Urinary Catheters
• Many patients hospitalized for a urinary
problem or disease receive catheterization.
• Urine backflow is a concern when
transporting a catheterized patient.
− Do not lift the drainage bag while handling the
patient.
Urinary Incontinence
• Loss of bladder control
• Medical problem if in one of two categories:
− Urge incontinence
− Overflow incontinence
Renal Calculi (Kidney Stones)
• Pathophysiology
− Originate in renal
pelvis
− Form when an
excess of insoluble
salts or uric acid
crystallizes in the
urine
© Jones & Bartlett Learning. Photographed by Kimberly Potvin.
Renal Calculi (Kidney Stones)
• Pathophysiology
(cont’d)
− Calcium stones
• Most common
• May have a
hereditary
component
− Struvite stones
• More common in
women
− Uric acid and
cystine stones
• Least common
Renal Calculi (Kidney Stones)
• Assessment findings
− Patients almost always experience pain.
− Patient may be restless or guard abdomen
• Palpation may be difficult.
− Vital signs vary.
Renal Calculi (Kidney Stones)
• Management
− Ensure ABCs.
− Position of comfort
− Administer analgesia if local protocols allow.
− Establish an IV line and administer fluids.
Acute Renal Failure (ARF)
• Sudden decrease in filtration through the
glomeruli
− Causes toxins to accumulate in the blood
• Two to seven percent of hospitalizations in
the United States
− Mortality rate of 50–80% in critical cases
Acute Renal Failure (ARF)
• Oliguria
− Urine output of less
than 500 mL/day
• Anuria
− Complete cessation of
urine production
• Patient may
experience:
− Generalized edema
− Acid buildup
− High levels of
nitrogenous
− High levels of
metabolic wastes in
the blood
Acute Renal Failure (ARF)
• If untreated, can
lead to:
− Heart failure
− Hypertension
− Metabolic acidosis
• Classified into
three types
− Based on where it
occurs
Acute Renal Failure (ARF)
• Pathophysiology
− Toxic buildup of nitrogenous wastes/salts in the
blood causes problems including:
• Impaired mentation
• Hypotension
• Fluid retention
• Tachycardia
Acute Renal Failure (ARF)
• Pathophysiology (cont’d)
− Prerenal ARF
• Caused by hypoperfusion of the kidneys
− Intrarenal acute renal failure (IARF)
• Involves damage to 1 of 3 areas of the kidney
− Postrenal ARF
• Caused by blockage of urine flow from kidneys
Acute Renal Failure (ARF)
• Findings may include:
−
−
−
−
−
−
Tinnitus
Anorexia
Hypertension
Altered mental status
Prolonged bleeding
Flank pain
• Look for any scars,
ecchymosis, or
distention on the
abdomen.
− Palpate for pulsing
masses.
• If available, a
hematocrit and
urinalysis may be
helpful.
Acute Renal Failure (ARF)
• Management
− Metabolic changes caused by ARF are life
threatening.
• Support the ABCs.
• Place in shock position.
− Many ARF patients have comorbid diseases.
Chronic Renal Failure (CRF)
• Pathophysiology
− Inadequate kidney
function caused by
the permanent
loss of nephrons
• Scarring occurs as
the damaged
nephrons cease to
function.
− Uremia and
azotemia develop.
− Systematic
complications
develop.
Chronic Renal Failure (CRF)
• Assessment findings
− Patients present with:
• An altered level of consciousness
• Hypotension
• Tachycardia
− Other signs and symptoms vary.
− Pericarditis and pulmonary edema are common.
Chronic Renal Failure (CRF)
• Management
− Similar to patients with ARF
− Patients will ultimately require renal dialysis.
− Due to electrolyte imbalances, be conservative
with treatment plans.
− Transport in a calm manner.
End-Stage Renal Disease
(ESRD)
• Pathophysiology
− Result of untreated acute or chronic renal failure
− Kidneys have lost all ability to function
• Fatal unless treated by dialysis or renal transplant
End-Stage Renal Disease
(ESRD)
• Initial signs and
symptoms:
−
−
−
−
−
−
Confusion
Shortness of breath
Peripheral edema
Bruising
Chest pain
Bone pain
• Signs and symptoms
of advanced ESRD
include:
−
−
−
−
Pruritus
Muscle twitching
Hallucinations
Hypotension
• In the late stages,
seizures/coma are
possible.
End-Stage Renal Disease
(ESRD)
• Management
− Treatment is limited to renal dialysis or kidney
transplant.
− Provide supportive care.
− Place the patient in the shock position.
Renal Dialysis
• Technique for:
− Filtering the blood
of its toxic wastes
− Removing excess
fluid
− Restoring the
normal balance of
electrolytes
• Two types:
− Peritoneal dialysis
− Hemodialysis
© Chris Priest/Photo Researchers, Inc.
Renal Dialysis
• Most patients undergoing chronic
hemodialysis have some sort of shunt.
Renal Dialysis
• You will usually only encounter dialysis
machines when transporting patients to and
from dialysis centers.
− Patients requiring dialysis usually undergo the
process every 2 or 3 days for 3 to 5 hours.
Renal Dialysis
• Patients who miss dialysis treatments often
present with signs of electrolyte imbalance.
• Other complications of dialysis include:
− Muscle cramps
− Nausea and vomiting
− Infections at the IV site
Renal Dialysis
Male Genital Tract Conditions
• Epididymitis
− Infection that causes inflammation of epididymis
along the posterior border of testis
• Orchitis
− When one or both testes become infected
• Prehospital management is supportive.
Male Genital Tract Conditions
• Fournier gangrene
− Causes infection and necrosis of the
subcutaneal tissue and muscle in the scrotum
− The scrotum will be spongy.
• Tissues will be gray-black.
− Prompt transport is required.
− Assess and treat for shock.
Male Genital Tract Conditions
• Priapism
− A painful, tender, persistent erection
− Maintain the patient’s privacy.
• Do not make assumptions about the cause.
− Treat the patient with respect.
• Ensure immobilization if you suspect spinal cord
injury.
Male Genital Tract Conditions
• Phimosis
− Inability to retract the
distal foreskin over the
glans penis
− Apply cold compress.
− Transport.
• Paraphimosis
− Foreskin is retracted
over the glans penis,
is entrapped
− True emergency
• Can result in
necrosis of the
glans
Male Genital Tract Conditions
• Benign prostate hypertrophy (BPH)
− Age-related nonmalignant enlargement of the
prostate gland
− May be asymptomatic, or may lead to:
• Difficulty starting urine flow
• Incomplete emptying of the bladder
• Increased urination at night
Male Genital Tract Conditions
• Testicular masses
− Rarely require prehospital treatment
− May present with or without pain
− Most are benign cystic masses or a varicocele.
• Testicular cancer usually presents as a painless
solid lump.
Male Genital Tract Conditions
• Testicular torsion
− Twisting of the testicle on the spermatic cord
• Medical emergency if twisting reduces blood flow to
testis
− Usually unilateral
− Transport carefully and promptly.
Summary
• Chronic kidney disease is the most common
renal disorder.
• The genitourinary system includes kidneys,
its structures, urinary bladder, ureters,
urethra, and reproductive organs.
• Blood flows through the kidney into the
afferent arteriole, then through the
glomerulus, then the efferent arteriole, and
finally the peritubular capillaries where it is
reabsorbed.
Summary
• Urine forms in the nephrons.
• In the glomerular capsule, filtrate from the
blood is converted into urine and is further
concentrated.
• In the distal convoluted tubule, the
composition of urine is further refined based
on the body’s needs. Antidiuretic hormone
and aldosterone are involved in adjusting
the urine.
Summary
• The juxtaglomerular apparatus releases
renin.
• Diuretics are chemicals that increase
urinary output.
• As urine collects in the bladder, the
micturition reflex causes the bladder to
contract, stimulating the urge to void.
• The female urethra is shorter than the male
urethra and more prone to UTIs.
Summary
• During the physical exam, use the fourquadrant system and abdominal region
mapping, perform cardiac monitoring, and
do not give anything orally.
• Visceral pain and referred pain are two
types of pain.
• Use OPQRST during assessments.
• Manage pain with positioning, analgesics
and fluids as indicated, and supportive care.
Summary
• Symptoms of a UTI include painful
urination, frequent urination, difficulty
urinating, and foul-smelling, cloudy urine.
Management is mainly supportive care of
the ABCs, keeping the patient in a position
of comfort, administering IV fluid, and
possibly administering analgesics.
• Catheterization of the bladder allows
continuous outflow of urine and is a means
to measure urine output. Avoid backflow.
Summary
• Kidney stones result when an excess of
insoluble salts or uric acid has crystallized
in the urine. Symptoms include severe flank
pain that may migrate to the groin.
• ARF results in a release of toxins into the
blood. The three types are prerenal,
intrarenal, and postrenal. Signs and
symptoms range from hypotension and
tachycardia to hematuria and peripheral
edema.
Summary
• CRF is progressive and irreversible
inadequate kidney function that leads to a
buildup of wastes and fluid in the blood.
• Patients with ARF or CRF require support of
the ABCs, administration of medications,
calm transport, and psychological support.
• Acute or chronic renal failure can progress
to end-stage renal disease.
Summary
• Renal dialysis removes toxic wastes and
excess fluids from the blood, usually
through a shunt, which connects the patient
to the dialysis machine.
• Dialysis patients must be monitored.
• Leaking shunts should be tightened. If it has
become disconnected at the vein, clamp the
cannula and disconnect the patient from the
machine.
Summary
• Epididymitis, Fournier gangrene, priapism,
phimosis, benign prostate hypertrophy,
testicular masses, and testicular torsion are
specific conditions to the male genital tract.
Prehospital management for most of these
conditions is supportive. Consider
administering analgesics; transport gently.
Credits
• Chapter opener: © Life in View/Photo Researchers, Inc.
• Backgrounds: Orange—© Keith Brofsky/
Photodisc/Getty Images; Blue—Jones & Bartlett
Learning. Courtesy of MIEMSS; Green—Jones &
Bartlett Learning; Purple—Jones & Bartlett Learning.
Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for Emergency
Medical Services Systems, or have been provided by
the American Academy of Orthopaedic Surgeons.