to the patient, the clinician should remove it by prying its jaws apart with a stick or metal object, holding a flame under the lizard’s chin, or submerging it in cold water [21]. Obviously, care should be taken to avoid additional bites to the patient or EMS personnel.
To determine the most appropriate destination facility for allergic reaction patients, it helps to consider the etiology of the reaction and the availability of certain subspecialties, such as otolaryngology, anesthesia, critical care, toxicology, and so on. They may be necessary to definitively treat the reaction. Transportation time should also be considered. If the patient is unstable or is likely to become unstable during an extended transport time to an appropriate facility, then air medical evacuation should be considered. Transport to the closest available facility for stabilization followed by transfer of the patient to a higher level of care is also an option. This will depend on the availability of air medical services, the distance to the closest facility, weather, traffic, terrain, and other conditions that must be factored in when making destination decisions.
Conclusion
Allergic reaction and anaphylaxis are frequently seen in the prehospital environment. EMS clinicians should be alert to the potential for rapid progression of allergic reactions to anaphylaxis and be prepared to hemodynamically support the patient and provide appropriate airway management. All patients with moderate or severe allergic reactions should be provided with oxygen, IV fluid administration, and continuous monitoring during transport. Clinicians should be familiar with the common medications and the dosages used to treat allergic reactions. Antihistamines and epinephrine are the mainstays of treatment. In cases of generalized allergic reaction and anaphylaxis, epinephrine administration should not be delayed. Early administration of epinephrine is critical in severe allergic reactions to prevent progression to anaphylaxis. Transport to an appropriate hospital should occur as soon as feasible.
References
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CHAPTER 22 Renal failure and dialysis
Jocelyn M. De Guzman and Bryan B. Kitch
Introduction
Renal failure in its various forms represents a spectrum of disease with profound implications for patient management. With differing etiologies for both acute and chronic forms of the disease, patients may present with a wide variety of complaints that directly relate to their renal function. This chapter will discuss the array of disorders, including acute, chronic, and end‐stage renal disease; their complications; and treatments most pertinent to EMS clinicians.
A brief review
According to the 2019 United States Renal Data System annual report, close to 750,000 people in the United States are living with end‐stage kidney disease (ESRD). Of those receiving treatment, 63% were undergoing hemodialysis, 7% peritoneal dialysis, and 30% had functional transplanted kidneys. While the number of prevalent cases continues to rise, the incidence of new cases has plateaued, owing to an increased number of patients starting renal replacement therapy, increased survival rates, and longer life expectancy of this population [1]. With the increasing number of ESRD patients potentially using the EMS system, the EMS physician must ensure that education about renal emergencies is an integral part of training and protocols.
Receiving approximately 20% of the body’s cardiac output, the kidneys function to filter blood through their 2 million nephrons. The series of microscopic and macroscopic elements serve to filter waste, complex metabolites, and excess fluids, exchange electrolytes, and manage acid and base regulation with the resultant fluid being excreted from the nephron. Additionally, the kidney controls red blood cell production with the production of erythropoietin and has a role in blood pressure regulation through renin secretion. Renal function is largely defined by estimated glomerular filtration rate in milliliter/minute/1.73 m2 (body surface area), with lesser values corresponding to more severe renal impairment [2].
Renal failure encompasses the entire spectrum of kidney malfunction including acute kidney injury, chronic kidney disease (CKD), and ultimately ESRD. Progression between acute and chronic disease is patient‐specific, dependent on several factors, including etiology of renal insult, reversibility of damage, and timeliness of treatment. While the specific pathophysiology differentiating each stage of disease will not be covered in this chapter, it is imperative for the EMS clinician to be able to identify and manage the emergent clinical presentations associated with renal failure.