ED Assessment & Management: CKD Stage 5, Missed Dialysis x 2 Months

Clinical Picture at a Glance

Immediate Life Threats to Identify (First 5 Minutes)

1. Severe Hyperkalemia (most immediately lethal)

• 2 months of missed HD = massive K+ accumulation
• Get 12-lead ECG immediately - do not wait for lab results
• ECG progression: peaked T waves → PR prolongation → absent P waves → wide QRS → sine wave → VF/asystole
• Per Rosen's EM: "If ECG changes are present, emergency treatment of hyperkalemia should start immediately. In a dialysis patient without known electrolyte levels, hyperkalemia should be suspected."
• With wide QRS (≥120ms) or absent P waves: cardiac arrest is imminent

2. Flash Pulmonary Edema / Fluid Overload

• Anuria/oliguria x 2 months = massive fluid accumulation
• No capacity for diuresis (essentially no kidneys)
• Bilateral crackles, SpO2 likely low, CXR will show pulmonary venous congestion/bat-wing pattern

3. Severe Metabolic Acidosis

• No H+ excretion for 2 months
• pH may be 7.1-7.2 or worse
• Worsens hyperkalemia (each 0.1 drop in pH shifts ~0.6 mEq/L K+ extracellularly)
• Kussmaul breathing may be contributing to "respiratory distress"

4. Uremic Complications

• Uremic pericarditis (risk of tamponade)
• Uremic encephalopathy
• Bleeding diathesis
• BUN likely severely elevated (Tintinalli's recommends keeping <100 mg/dL as a general guide)

Investigations (Simultaneous with Resuscitation)

• 12-lead ECG - FIRST, before anything else
• ABG - assess pH, pCO2, HCO3, SpO2
• Serum K+, Na+, BUN, Creatinine
• Serum Mg2+, Ca2+, Phosphate
• CBC (anemia of CKD will be severe)
• Blood glucose
• CXR (portable AP)
• Troponin, BNP/NT-proBNP
• Blood cultures if febrile (HD patients are immunocompromised)
• Bedside echo (pericardial effusion? LV function? IVC size?)

Emergency Management

Step 1: Stabilize (simultaneous with investigations)

• High-flow O2 (NRB mask or NIV/CPAP for pulmonary edema)
  • CPAP/BiPAP is preferred for cardiogenic pulmonary edema - reduces preload and work of breathing
• IV access x2 (large bore)
• Cardiac monitoring, pulse oximetry
• Sit patient upright

Step 2: Treat Hyperkalemia (ECG-guided)

• IV Calcium Gluconate 10% - 10 mL (1g) slow IV over 2-3 min
  • Restores resting membrane potential, does not lower K+
  • Effect within 1-3 min, lasts 30-60 min
  • If QRS remains wide after 5 min: repeat dose
  • Use calcium chloride if central access (3x more elemental Ca2+)

• Insulin + Glucose: Regular insulin 10 units IV + 50 mL of 50% dextrose (D50)
  • Onset 15-30 min, lowers K+ by 0.6-1.0 mEq/L
  • Monitor glucose at 30, 60, 120 min post-dose
• Nebulized Salbutamol (Albuterol): 10-20 mg nebulized
  • Lowers K+ by 0.5-1.0 mEq/L additional to insulin
  • Additive effect
• IV Sodium Bicarbonate: 50-100 mEq if pH <7.2
  • Modest K+-shifting effect; more useful for severe acidosis

• Emergent Hemodialysis - the only definitive treatment
  • This patient needs HD immediately - it addresses K+, acidosis, AND fluid overload simultaneously
  • Per Tintinalli's: "Immediate ultrafiltration or other renal replacement therapy should be considered for life-threatening hyperkalemia or pulmonary edema unresponsive to less invasive treatment"

Step 3: Manage Pulmonary Edema (while arranging HD)

• IV Furosemide (high dose - 200-400 mg IV) may be tried if any residual renal function exists - mainly for vasodilation effect
• Morphine 2-4 mg IV - reduces anxiety, preload (use cautiously in respiratory distress; may need to avoid if risk of obtundation)
• GTN (Nitrates) - sublingual or IV if BP allows - reduces preload
• NIV (CPAP/BiPAP) - strongest non-HD intervention for pulmonary edema

Step 4: Manage Metabolic Acidosis

• Treat via HD (definitive)
• IV Sodium Bicarbonate for pH <7.1 or HCO3 <10 as a bridge, but use cautiously in fluid-overloaded patient (Na+ load worsens pulmonary edema)

Airway Decision

• GCS falling or unable to protect airway → RSI intubation
• AVOID succinylcholine in this patient - it causes K+ release of ~0.5-1 mEq/L, which can precipitate cardiac arrest in someone already severely hyperkalemic
• Use Rocuronium (1.2 mg/kg) for RSI instead
• Per Rosen's: "Succinylcholine is contraindicated in patients with known or presumed hyperkalemia in the setting of missed dialysis"

Disposition

• ICU admission - mandatory
• Urgent nephrology consult for emergent HD
• Cardiology if pericardial effusion / significant cardiac compromise
• Dialysis access assessment (AV fistula - check for thrill/bruit; may need temporary line if no access)

Summary Algorithm

Patient arrives → ECG STAT
                    ↓
         ECG changes? (peaked T, wide QRS)
                    ↓ YES
         Ca Gluconate IV immediately
                    ↓
         Insulin + Glucose + Nebulized Salbutamol
                    ↓
         NIV/CPAP for respiratory distress
                    ↓
         EMERGENT HEMODIALYSIS (definitive)
         - Removes K+
         - Removes fluid (ultrafiltration)
         - Corrects acidosis
         - Removes uremic toxins

Key Pitfalls to Avoid