care, it is imperative to communicate clearly about what treatment has been administered. Otherwise, serum potassium assays may be falsely reassuring to the next clinical team.
Rapid sequence intubation and hyperkalemia
The EMS clinician performing rapid sequence intubation (RSI) should avoid depolarizing neuromuscular blocking agents (NMBA) such as succinylcholine in patients who are at risk for being hyperkalemic. Along with the renal failure population, those patients with muscular dystrophy, stroke > 72 hours, crush injury > 72 hours, and burns > 72 hours old are at increased risk of severe hyperkalemia with the use of depolarizing NMBAs due to an upregulation of acetylcholine receptors. Fatal arrhythmias can develop within minutes and the EMS clinician must recognize and appropriately initiate treatment as discussed above. It is recommended that nondepolarizing NMBAs such as rocuronium be used instead for this patient population should RSI be required [39].
Use of dialysis access for resuscitation
The use of an ESRD patient’s dialysis access in the prehospital setting should be reserved for the critical, rapidly decompensating patient when intravenous and intraosseous access cannot be obtained during resuscitation efforts. While the risks of complications (e.g., thrombosis, infection) may ultimately result in the loss of the patient’s graft, fistula, or catheter, these issues can be dealt with later, pending the patient’s survival.
Both AV fistulas and AV grafts can be accessed in a fashion similar to starting a peripheral intravenous line. Gloves, eye protection, and a mask should be used along with aseptic technique to the extent possible. A tourniquet should be loosely applied to the axilla proximal to the access site, tight enough to cause the vessel to engorge, and be removed immediately after cannulation of the fistula or graft. A large‐bore needle (14, 16, or 18 gauge) with or without an angiocatheter should be inserted into the fistula at 20‐35 degrees (45 degrees for graft access) until a flash of blood is seen. The needle should be advanced 3‐4 mm before flattening the angle of insertion flat against the skin and threading the needle alone or with a catheter until the hub rests against the insertion site. The line needs to be secured in place. Due to the high‐velocity blood flow in the graft and fistula, saline lock tubing and a pressure bag for fluids will be needed, especially for access using an angiocatheter. When appropriate, the EMS clinician should assess for a thrill at the access site and relay this information to the receiving facility [40].
Dialysis catheters, whether tunneled or nontunneled, essentially function as central lines. The dialysis catheter usually has two lumens attached to two ports, red and blue. The red port is considered arterial and the blue port venous, tasked with bringing filtered blood from the dialysis machine back to the heart. A third port, white in color, may be present specifically for blood draws and medication administration. In the absence of the white port, the blue “venous” port should be used for emergency administration of drugs and fluids. Personal protective equipment should be donned to keep the procedure as sterile as possible. The port cap should be cleaned with chlorhexidine or alcohol, and the lumen should be clamped while the cap is removed. After cleaning the catheter hub, a syringe should be attached, and the lumen unclamped. As information regarding the locking fluid present in the catheter will likely not be immediately available to the EMS clinician, fluid and blood should be withdrawn with a 10 cc syringe and wasted before administration of medications. This is to prevent inadvertent systemic administration of the locking solution. The lumen should be flushed and clamped after drug administration. Replacement of locking fluid and caps can occur in the hospital setting.
During emergency transport from a dialysis center, the staff at the facility may leave the ESRD patient’s vascular device accessed. EMS personnel should be aware of this as a potential site for emergency drug administration and should protect the access point from trauma.
EMS pearls
Focused history
When the EMS clinician encounters a dialysis patient, a set of focused questions to the patient and any family/dialysis clinic staff present can be quite helpful to subsequent treatment teams.
Dialysis schedule – Knowing what days of the week the patient has dialysis, as well as the day of the most recent session is useful.
Length of sessions – Attempt to determine how many hours each dialysis session is, as well as if the patient is completing the full length each time, with attention to the last session. If transporting from the dialysis center, it is important to determine whether the session was completed, partial, or not even started.
Volume status – Each patients should have a known “dry weight,” which is the ideal euvolemic weight. Additionally, knowing the patient’s current weight can greatly help with fluid status assessment. The patient or dialysis center staff may also be able to state how much weight/fluid is removed with each dialysis and/or the current net fluid volume.
Vital signs – Dialysis patients may have “abnormal” vital signs at baseline. If so, careful documentation of the patient’s baseline heart rate and blood pressure is important. Refrain from using the limb on the same side of hemodialysis access to prevent complications like thrombosis.
Urine output status – Whether or not an ESRD patient is still able to make urine for diuresis is often helpful in treatment decisions of the fluid overloaded patient.
Destination selection
Should a patient with ESRD require transport, it may be necessary to choose a destination hospital that can care for his or her needs. Even if the patient is not presenting to EMS for a dialysis‐related complaint, should he or she require admission, renal replacement therapy will be required, eventually. The greater risk of coronary artery disease and stroke may necessitate specialty care more often than in the otherwise healthy nondialysis patient. Local protocols may be developed to address this specific patient population and its particular needs.
Resource planning
The individual in the community who is dialysis dependent requires unique resources for his or her survival. While under normal conditions the patient likely has established mechanisms for obtaining transportation and treatment, this system can be disrupted in the case of a disaster or disruptive weather event. The local emergency management agency should work alongside EMS medical directors and the dialysis providers to develop contingency plans appropriate for the local environment. Large dialysis center networks may operate a central command/tracking system that can be a resource for planning and disaster management. Other government and local agencies will need to contribute to this planning process, as operation of a hemodialysis machine requires infrastructure that is easily disrupted. Identification and registry of the patients who will require emergent dialysis services in times of need can allow for continued access to life‐sustaining care.
Convalescent Transportation
Hemodialysis patients have a frequent need for transportation to a medical facility for regular treatment sessions. Patients may require assistance in this regard, relying on nonemergency transportation services. There exists a wide variety in the training level of personnel handling this form of transportation. People in this field may become well acquainted with their “regular” dialysis patients and be able to recognize subtle changes in their condition, which may require diversion to a higher level of care. Protocols should be established to assist in the recognition of emergencies in this high‐risk population. If the particular transport unit does not possess the capabilities to care for emergency medical conditions, personnel should know the best method of accessing the resources required to do so.
References
1 1 National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. United States Renal Data System. 2019 USRDS Annual