1. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Paramedic Care: Principles & Practice Volume 3 Medical Emergencies

2. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chapter 7 Urology and Nephrology

3. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Topics Anatomy and Physiology General Mechanisms of Nontraumatic Tissue Problems General Pathophysiology, Assessment, and Management Renal and Urologic Emergencies

4. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Introduction The urinary system performs a number of vital functions: –Maintains blood volume and the proper balance of water, electrolytes, and pH (acid-base balance) –Removes a variety of toxic wastes from the blood –Maintains arterial blood pressure –Controls development of red blood cells

5. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology

6. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology The Urinary System –Female –Male Urology and Nephrology

7. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ The Urinary System Click here to view an animation on urine.here

8. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology The Kidneys –Hilum –Medulla –Pyramids –Papilla –Renal Pelvis

9. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Nephrons –Glomerulus –Bowman’s Capsule –Proximal Tubule –Loop of Henle –Distal Tubule –Collecting Duct Anatomy and Physiology

10. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Formation of Urine –Glomerular Filtration GFR –Reabsorption and Secretion Simple diffusion and osmosis Facilitated diffusion Active transport Anatomy and Physiology

11. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Anatomy and Physiology Tubular Handling of Water and Electrolytes –Diuresis and Antidiuresis Tubular Handling of Glucose and Urea –BUN and Creatinine Control of Arterial Blood Pressure –The Renin-Angiotensin System Control of Erythrocyte Production –Erythropoietin

12. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Ureters Urinary Bladder Urethra Testes Epididymis and Vas Deferens Prostate Gland Penis Anatomy and Physiology

13. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Mechanisms of Nontraumatic Tissue Problems

14. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Mechanisms of Nontraumatic Tissue Problems Inflammatory or Immune-Mediated Disease Infectious Disease Physical Obstruction Hemorrhage

15. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Pathophysiology, Assessment, and Management

16. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ General Pathophysiology, Assessment, and Management Differentiating GI and Urologic Complaints Pathophysiologic Basis of Pain –Causes of Pain –Types of Pain Visceral pain Referred pain

17. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management Scene Size-up Initial Assessment Focused History –OPQRST History –Prior History of Similar Event –History of Nausea, Vomiting, and Weight Loss –Change in Bowel Habits and Stool –Last Oral Intake –Presence of Chest Pain

18. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management Physical Exam –Appearance Uncomfortable appearance –Posture Lying with knees drawn up Relief with walking –Level of Consciousness Determine if changes are acute or chronic

19. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management Apparent State of Health Skin Color Examination of the Abdomen –Inspection for Distention, Ecchymosis, or Scarring –Pain Associated with Percussion of Abdomen –Palpation Normal or ectopic pregnancy Masses Assessment Tools Vital Signs

20. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Assessment and Management Management –Airway, Breathing, Circulation –Pharmacologic Interventions IV access and analgesics –Nonpharmacological Interventions Nothing by mouth (NPO) Maintain position of comfort Reassess mental status and vital signs frequently –Transport Considerations

21. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Renal and Urologic Emergencies

22. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Renal and Urologic Emergencies Risk Factors –Older Patients –History of Diabetes –History of Hypertension –Multiple Risk Factors Renal and Urologic Emergencies –Acute Renal Failure –Chronic Renal Failure –Renal Calculi –Urinary Tract Infection

23. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure Sudden drop in urine output to less than 400-500 cc/day –Oliguria Pathophysiology –Prerenal Acute Renal Failure Dysfunction before the level of kidneys Most common and most easily reversible –Renal Acute Renal Failure Dysfunction within the kidneys themselves –Postrenal Acute Renal Failure Dysfunction distal to the kidneys

24. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure

25. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure Assessment –Focused History Change in urine output Swelling in face, hands, feet, or torso Presence of heart palpitations or irregularity Changes in mental function

26. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure Physical Assessment –Altered mental status –Hypertension –Tachycardia –ECG indicative of hyperkalemia –Pale, cool, moist skin

27. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Physical Assessment (cont.) –Edema of face, hands, or feet –Abdominal findings dependent on the cause of ARF Acute Renal Failure

28. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Acute Renal Failure Management –Airway, Breathing, Circulation –IV Access Protect fluid volume –Positioning and Transport Consider nephrotoxic medications Eliminate or discontinue if unsure

29. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure –Permanent loss of nephrons –End-Stage Renal Failure (ESRF) Pathophysiology –Similar to Renal ARF Microangiopathy, glomerular injury Tubular cell injury Insterstitial injury

30. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure

31. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure Impairment of Kidney Functions –Maintenance of blood volume with proper balance of water, electrolytes, and pH Increased sodium, water, and potassium retention –Retention of key compounds such as glucose with excretion of wastes such as urea Loss of glucose and buildup of urea within the blood –Control of arterial blood pressure Disruption of the renin-angiotensin loop resulting in hypertension –Regulation of erythrocyte development Development of chronic anemia

32. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure Assessment –Differentiate chronic and acute problems –Focused history and physical exam Gastrointestinal complaints Changes in mental status Marked abnormalities during physical exam Uremic frost

33. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure

34. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure Immediate Management –Monitor and support ABCs –Establish IV access Regulate fluid volume –Monitor vital signs and cardiac rhythm –Expedite transport to an appropriate facility

35. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure Long-Term Management –Hemodialysis –Common complications Bleeding from the needle puncture site Local infection Narrowing or closing of the internal fistula

36. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Chronic Renal Failure Long-Term Management –Chronic ambulatory peritoneal dialysis (CPAD) Utilizes the peritoneal membrane Avoids some of the shifts in fluid and electrolyte balance –Complications

37. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Pathophysiology –“Too much insoluble stuff” and “too concentrated” urine accumulates –Stone types: Calcium salts Struvite stones Uric acid Cystine © SIU/Photo Researchers Renal Calculi

38. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Renal Calculi Assessment –Focused History Severe pain in one flank that increases in intensity and migrates from the flank to the groin Painful, frequent urination with visible hematuria Prior history of calculi –Physical Exam Difficult due to patient discomfort Tachycardia with pale, cool, and moist skin

39. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Renal Calculi Management –Maintain ABCs –Maintain position of comfort –Establish IV access Fluid bolus may promote stone movement and urine formation and promote pain relief –Consider medication administration Use caution with narcotic analgesics if possible GI origin

40. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Priapism Painful and prolonged erection of the penis. Priapism affects only the corpora cavernosa. The corpora spongiosum remains flaccid. The most common cause of nontraumatic priapism is sickle cell disease.

41. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Priapism Other causes of priapism include: –Leukemia –Multiple myeloma –Tumors –Spinal cord injury –Spinal anesthesia –Carbon monoxide poisoning –Malaria –Black widow spider bites –Prescription and non-prescription drugs Treatment

42. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection Pathophysiology –Risk Factors Increased risk in female or catheterized patients Sexual activity –Lower and Upper UTIs Urethritis Cystitis Prostatitis Pyelonephritis Community-acquired vs. nosocomial infections

43. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection Assessment –Focused History Abdominal pain Frequent, painful urination A “burning sensation” associated with urination Difficulty beginning and continuing to void Strong or foul-smelling urine Similar past episodes

44. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Urinary Tract Infection Assessment –Physical Exam Restless, uncomfortable appearance Presence of a fever Vital signs vary with degree of pain Management –Maintain ABCs –Establish IV access –Consider analgesics –Transport to appropriate facility

45. Bledsoe et al., Paramedic Care: Principles & Practice, Volume 3: Medical Emergencies, 3rd Ed. © 2009 by Pearson Education, Inc. Upper Saddle River, NJ Summary Anatomy and Physiology General Mechanisms of Nontraumatic Tissue Problems General Pathophysiology, Assessment, and Management Renal and Urologic Emergencies