The Medical Patient The Renal System Hypertensive Emergencies

1
The Medical PatientThe Renal System
Hypertensive Emergencies

• Condell Medical Center
• EMS System
• October 2008 CE
• Site Code 10-7200E1208

Prepared by Sharon Hopkins, RN, BSN, EMT-P
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Objectives

• Upon successful completion of this module, the
  EMS provider should be able to
• List the components and function of the urinary
  system
• State signs and symptoms of chronic kidney
  disease
• Define hemodialysis
• Identify the differences between AV fistulas and
  AV shunts implications in the field
• Apply the Renal SOPs given a scenario
• List the steps in performing an abdominal
  assessment

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• Describe the physical assessment of the patient
  with flank pain
• Describe the management of the patient with flank
  pain
• Define the criteria for a hypertensive emergency
• List the signs and symptoms of hypertensive
  emergencies
• Describe the rationale for treatment using Lasix
  and Nitroglycerin for hypertensive emergencies
• Describe the proper technique to obtain a blood
  pressure
• Describe the components of a neurological
  assessment

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• Successfully calculate the GCS given the findings
  of the patient assessment
• Return demonstrate pupillary assessment
• Return demonstrate the in-line Albuterol
  set-up
• Return demonstrate the preparation of an
  Amiodarone IVPB set-up
• Identify and appropriately state interventions
  for a variety of EKG rhythms
• Identify ST elevation on a 12 lead EKG
• Successfully complete the 10 question quiz with a
  score of 80 or better

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Urinary System

• Contains 4 major structures
• Kidneys
• Vital organs
• Located in upper abdomen retroperitoneal area
• 1 behind the spleen 1 behind the liver
• Ureters
• Urinary bladder
• Urethra

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Function of the Urinary System

• Major functions
• Maintains blood volume via proper balance of
  water, electrolytes, and pH
• Retains key compounds (ie glucose) and
  eliminates wastes (ie urea)
• Monitors and maintains arterial blood pressure
  (in addition to other mechanisms)
• Regulates erythrocyte (RBC) development

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Urinary Bladder

• Storage receptacle for the production of urine
  until it is convenient or necessary to void
• Fully distended can hold 500 ml of urine
• The more distended the bladder, the more
  vulnerable to blunt trauma
• After urination, the bladder contains about 10 ml
  of fluid

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Chronic Kidney Disease

• Can be from a specific kidney disease or as a
  complication from other conditions
• Diabetes
• 1 reason in USA for need for kidney transplant
• Hypertension
• Kidney inflammation (glomerulonephritis)
• Inflammation of blood vessels (vasculitis)
• Polycystic kidney disease

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Chronic Kidney Disease

• Diseased or injured kidneys
• Blood flow through the renal system decreases
• Inflammatory changes occur in the glomeruli
• A group of capillaries where blood is filtered
  into a nephron (structure that produces urine)
• Capillary walls thicken decreasing permeability
• Glomerular filtration rate (GFR) is reduced
• Volume of blood filtered per day thru glomeruli

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Symptoms of Chronic Kidney Disease

• Most common symptoms
• Swelling, usually of lower extremities
• Fatigue
• Weight loss, loss of appetite
• Nausea and/or vomiting
• Change in urination
• Reduction in volume or frequency
• Change in sleep patterns
• Headache
• Itching high levels of phosphorus in system
  dry skin
• Difficulties with memory or concentration

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Complications of Chronic Kidney Disease

• Hypertension
• May be a leading cause but can also develop in
  the early stages as a complication
• Anemia
• Decreased production of red blood cells
• Bone disease
• Disorders of calcium and phosphorus
• Malnutrition
• Altered functional status and well-being

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Dialysis

• Dialysis is required when the kidneys fail and a
  transplant is not performed
• Peritoneal dialysis uses a catheter thru the
  abdominal wall to filter the blood

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Hemodialysis

• Hemodialysis is a procedure in which a machine
  filters harmful waste and excess salt and fluid
  from your body
• Access points are created to be functional within
  weeks and to last several to many years
• Usual access point is the forearm

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Fistulas and Shunts

• Arteriovenous (AV) fistula
• Most common type of access
• Fistula created internally by sewing an artery to
  a vein forming a small opening between the two
• Pressure from the arterial flow eventually
  enlarges and strengthens the vein
• May take 6 weeks to heal but can last for years

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• Arteriovenous (AV) graft
• Access is similar to a fistula
• A synthetic tube is used to surgically connect
  the artery to the vein
• AV graft often heals within 2-3 weeks
• With proper care, can last several years
• Higher likelihood of forming clots or becoming
  infected than an AV fistula

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Renal Dialysis
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Hemodialysis

• Most people treated with hemodialysis 3 times a
  week
• Each session lasts approximately 3-5 hours
• Some patients, at some dialysis centers, may
  choose daily dialysis
• Usually performed 6 days per week for 2 21/2
  hours each session
• Patients often report improved B/P and quality of
  life

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Continuous Ambulatory Peritoneal Dialysis

• CAPD is a self-care treatment where the patient
  instills dialysate fluid into the peritoneal
  (abdominal) cavity through a surgically implanted
  catheter through the abdominal wall
• The dialysate stays in the abdominal cavity a
  prescribed period of time and then is drained out

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CAPD Instructions

• Do not disconnect the CAPD bags from the catheter
• If the patient is transported, transport with the
  drainage bag remaining below the level of the
  patients waist
• Do not infuse any fluids or medications directly
  into the catheter
• This IS NOT an alternate IV site
• Transport the patient with the CAPD intact

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Renal ProtocolCare of Patients with Grafts or
Shunts

• Do NOT take B/P on arm with active fistula or
  graft
• Do NOT start IV on arm with active fistula or
  graft
• If site is bleeding, apply direct pressure
• In case of arrest and no IV access consider IO
  site
• Access of fistula or graft is only with contact
  to Medical Control

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Care of The Renal Patient

• Best to err on the side of conservative treatment
• Monitor and support the ABCs
• High flow O2 is appropriate to maximize
  respiratory efficiency
• Carefully monitor fluid administration
• Monitor cardiac rhythm for disturbances
• Caregivers can help manage the additional
  equipment on the patient

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Abdominal Pain Assessment

• Chief complaint
• The sign or symptoms that prompted the patient to
  call for help
• Use an open ended question to determine the
  reason for the call
• Why did you call us today? or
• What seems to be the problem?
• During the interview the chief complaint
  generally becomes more specific

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Assessment

• O onset of the problem
• Did problem start suddenly or gradually?
• What was patient doing at the time?
• P provocation/palliation
• What makes the symptoms worse? Better?
• Q quality
• In the patients own words how do they describe
  their pain (ie crushing, tearing, sharp, dull?)

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• R region/radiation
• Where is the symptom?
• Does it move?
• If the patient uses one finger or isolates to one
  spot, the pain is considered localized
• If the pain is described using both hands or
  indicating a larger area, the pain is diffuse
• Is there referred pain (pain felt in a body area
  away from the source)?

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• S severity
• Intensity of pain or discomfort
• 0 10 scale
• 0 is no pain 10 is the worse pain in your
  life
• Can the patient be distracted?
• Do they lie still or are they writhing about?
• T time
• When did the symptoms begin?

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• Associated symptoms
• Are other symptoms present that are commonly
  linked to certain diseases that can help rule in
  or out your diagnosis?
• Pertinent negatives
• Are any likely associated symptoms absent?
• Absence of symptoms can be information as helpful
  as presence of other symptoms

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Assessment Pitfalls in the Chronic Renal Patient

• The challenge to the medical professional is to
  separate the acute complaint from the chronic
  condition
• What is new today that changes your status?
• Many of these patients have unstable baselines to
  start with
• Fluid and electrolyte imbalance
• EKG disturbances

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Physical Assessment - Abdomen

• Boundaries run from xiphoid process to symphysis
  pubis
• A full bladder will distort assessment and
  increase discomfort for the patient
• To relax the abdominal wall or to ease pain, a
  pillow placed under the knees would be helpful
• Start by asking the patient where it hurts
• Examine painful areas last

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• Warm your hands and stethoscope
• If hands are cold, palpate over clothing until
  hands warm up
• Monitor facial expressions for pain or discomfort
• Validate the facial expression
• Often the patient scrunches their face in
  anticipation of pain
• Assessment techniques to use
• Inspection, auscultation, percussion, lastly
  palpation

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Abdominal Assessment Techniques

• Inspection
• A visual review looking for abnormalities
• Auscultation
• Move the stethoscope in a circle approximately 2
  inches from the umbilicus listening for bowel
  sounds
• Normal bowel sounds gurgle approximately every
  5-15 seconds

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• Percussion
• Not often performed in the field
• Helps determine size and location of organs
• Determines gas, solid, and fluid filled areas
• Tympany heard over most of abdomen
• Dullness percussed over spleen and liver

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• Palpation
• Palpate painful areas last
• To increase comfort to patient, have them take
  slow, deep breaths thru open mouth
• Flexing knees relaxes abdominal wall
• Abdominal pain on light palpation indicates
  peritoneal irritation or inflammation
• Voluntary guarding patient anticipates pain or
  is not relaxed
• Involuntary guarding peritoneal inflammation
  (lining of abdominal cavity)

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SOP Abdominal Pain Stable Patient

• Routine medical care
• Watch the patient for vomiting
• Stable patient
• Patient alert
• Skin warm and dry
• Systolic B/P 100 mmHg
• Contact Medical Control for pain management

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SOP Abdominal Pain Unstable Patient

• Routine medical care
• Watch the patient for vomiting
• Unstable patient
• Altered mental status
• Systolic B/P
• Establish IV x2 if possible
• Fluid challenge in 200 ml increments
• 20 ml/kg in pediatric patient (max 3 challenges)
• Contact Medical control for pain management

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Flank Pain

• Wheres the flank?
• The area of the back below the ribs and above the
  hip bones
• What organs lie in the flank areas?
• The kidneys
• What is a common reason for flank pain?
• Renal calculi (aka kidney stones)

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Causes of flank pain
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Kidney Stones

• The formation of crystals in the kidneys
  collection system
• Hospitalization common for pain control and fluid
  hydration
• Additional inpatient treatment may be necessary
• Lithotripsy sound waves used to break apart
  larger stones into smaller ones that can be
  passed during urination

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Kidney Stones

• More common in males
• Suggestion of hereditary patterns
• Risk factors include immobility and certain
  medications (anesthetics, opiates, psychotropic
  drugs)
• Stones can form in metabolic disorders (ie gout)
• Production of excessive uric acid and calcium

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Stones From Calcium Salts

• The most common type of stone
• 75 85 of all stones
• Calcium stones 2 3 times more common in men
• Average age of onset 20 30 years
• Familial indication
• History of one stone and patient likely to form
  another one within 2 3 years

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Struvite Stones

• Represent 10 15 of all stones
• Formation associated with chronic urinary tract
  infection or frequent bladder catheterization
• Patients with spinal cord injuries
• Patients with spina bifida
• More common in women (due to their higher
  incidence of UTIs)

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Uric Acid Stones

• The least common of all stones
• Form more often in men
• Tend to occur with family histories so most
  likely a hereditary component
• Half of patients with uric acid stones have gout

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Patient Assessment

• Chief complaint almost always severe pain
• Kidney stones considered to be the most painful
  medical condition
• Pain started vague, dull, poorly localized
  (visceral pain) in one flank
• Within 30 60 minutes pain is extremely sharp,
  remains in the flank and radiates downward and
  anteriorly to the groin

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Physical Exam

• Agitated, restless, uncomfortable patient
• B/P and heart rate elevated with the pain
• Skin typically pale, cool, clammy
• Patient may not be able to lie still for
  abdominal examination
• Observed urine sample may have gross hematuria or
  will be evident in lab analysis

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Management

• Position of comfort
• Be prepared for vomiting (due to pain)
• IV fluids for volume replacement and as a drug
  route, and to promote urine formation and
  movement through the system to flush through the
  stone
• Analgesia for pain limited amounts used in the
  field often have minimal effect, if at all

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SOP Flank Pain

• SOP treatment same as abdominal pain
• Call Medical Control to obtain pain medication
  orders
• Be patients advocate for pain control
• Kidney stones are considered the most painful
  human condition (just ask someone who has had
  one!)

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Hypertensive Emergency

• A life-threatening crisis with an acute elevation
  of the blood pressure
• Systolic B/P 230 mmHg
• Diastolic B/P 120 mmHg
• Usually seen in patients with untreated or poorly
  controlled hypertension

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Hypertensive Emergency

• Signs and symptoms
• Epistaxis nosebleed
• The nasal tissue is very thin and prone to bleed
• Headache
• The worst headache in my life often indicates a
  subarachnoid bleed
• Visual disturbances (ie blurred, blindness)

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• Restlessness
• Confusion
• Nausea and vomiting
• Neurologicial changes
• Altered mental status to seizures to coma
• Complications
• Hypertensive encephalopathy
• Severe headache, vomiting, visual changes,
  paralysis, seizures, stupor, coma
• Ischemic (clot) or hemorrhagic (bleed) stroke

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Field Assessment

• Chief complaint received is often headache
• Additional accompanying complaints
• Nausea and/or vomiting
• Blurred vision
• Shortness of breath
• Epistaxis (nosebleed)
• Vertigo (dizziness)
• Level of consciousness may be normal, altered, or
  patient may be unconscious

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Field Assessment

• Findings
• Skin may be pale, flushed, or normal
• Skin may be warm or cool moist or dry
• If hypertensive encephalopathy is present, it may
  cause left ventricular failure
• Patient will be in pulmonary edema
• Lung sounds clear unless in pulmonary edema
• Pulse often strong and bounding

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SOP - Hypertensive Emergency

• Routine Medical Care
• Obtain and record the B/P in both arms
• Monitor record vital signs and neuro status
  every 5 minutes
• Lasix 40 mg IVP
• 80mg if already on Lasix at home
• Contact Medical control for further orders
• Possible Nitroglycerin order

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Treating Hypertensive Emergencies

• Initial goal
• To achieve a progressive, controlled reduction in
  the blood pressure to minimize risks of
  hypoperfusion in the vascular beds in cerebral,
  coronary, and renal blood flow
• Goal is not to reduce the blood pressure to
  normal levels as fast as possible

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Why Give Lasix?

• Lasix is a venodilator and a diuretic
• By dilating blood vessels, blood pressure can be
  decreased
• Venodilator effect noticed before evidence of
  diuretic effects are seen
• Decreasing fluid volume is another method to
  reduce the blood pressure by reducing the volume
  to be pumped

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Why Give Nitroglycerin

• Primarily a venodilator
• Will dilate the diameter of blood vessels
• Decreases blood pressure
• Especially useful in the patient with coronary
  ischemia
• Still need to screen for use of Viagra or Viagra
  type drugs in the past 24-36 hours

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Obtaining A Blood Pressure
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Blood Pressure Measurement

• Poor technique can result in inaccurate values
• Patients arm should be at the same vertical
  height as the heart
• The cuff bladder should fit snugly around the arm
• The lower edge of the cuff should be placed 1
  inch above the brachial artery
• The bladder should be centered over the brachial
  artery

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• The bell end of the stethoscope will produce
  better sounds
• The diaphragm is easier to place and hold with
  one hand
• The cuff and tubing should not be touching
  clothes which can give false sounds
• After the cuff is pumped up, the air should be
  released slowly
• Air released too fast may cause an inaccurate
  measurement to be read
• Cracked tubing causes air to leak too fast

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Obese Site B/P Cuff

• Wrap the blood pressure cuff around the forearm
• Center the bladder over the radial artery
• Place the stethoscope over the radial artery
• Obtain and document the blood pressure in the
  usual manner (ie 120/80)

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Blood Pressure by Palpation

• Rough estimation of the systolic value
• Palpate for the loss of the radial or brachial
  pulse and continue to inflate the cuff an
  additional 30 points
• Slowly release the air and when the pulse is
  first felt, this is the recorded systolic B/P
• Document the reading as 100/palpation

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Rough Estimate of Blood Pressure By Palpation

• A rough guideline accuracy is debatable
• If the radial pulse is palpated, the B/P is said
  to be roughly 80 mmHg
• If the femoral pulse is palpated, the B/P is said
  to be roughly 70 mmHg
• If only the carotid (central) pulse is felt, the
  B/P is said to be roughly 60 mmHg

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A Neuro Assessment

• Level of consciousness
• A alert (means awake but not necessarily
  oriented spontaneous eye opening responds to
  voice but can be confused and has motor function
  )
• V responds to verbal command no matter how
  slight and type of response
• P responds to pain or tactile stimuli only
• U unresponsive with no eye, voice, or motor
  response at all to voice or pain

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• Ask 2 questions to determine level of
  consciousness
• What month is this?
• How old are you?
• Obtain the Glasgow Coma Scale (GCS) on all EMS
  patients
• Best eye opening (4 points)
• Best verbal response (5 points)
• Best motor response (6 points)
• Evaluate pupillary response

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Performing a Pupillary Check

• Ask patient to focus on an object (ie tip of
  your nose)
• Bring the light in from the side and out the same
  way
• Without shining in the eyes move the penlight
  into position for the opposite side and repeat

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• Vital signs
• Signs of increasing intracranial pressure include
  increasing B/P and dropping heart rate
• Check muscle tone and strength
• Evaluate facial symmetry (smile)
• Evaluate clarity of speech
• The above 3 are the Cincinnati Stroke Scale
• Arm drift, facial symmetry, speech
• Additionally
• Coordination or gait and sensory
• Movement and sensation

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Repeat Assessment

• If you want to see where the patient is going,
  youve got to know where theyre coming from
• GET A BASELINE EVALUATION
• You can anticipate something happening if you are
  watching the trends
• PERFORM REPEAT ASSESSMENTS AS OFTEN AS INDICATED
• Prevents surprises

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• Need to constantly monitor the situation
• Watch for trends
• Anticipate surprises

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Pain Management SOP

• Routine trauma or medical care
• Continuous patient monitoring
• Respiratory status
• SaO2
• Blood pressure
• Morphine
• 2 mg slow IVP over 2 minutes
• May repeat every 2 minutes
• Maximum total 10 mg

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Respiratory Depression Related to Morphine Use

• Supportive oxygenation
• If SaO2 is falling and ventilation rates are
  declining, consider supportive bagging
• Ventilation rates for supportive bagging (AHA)
• Adult 1 breath every 5 6 seconds
• Pediatric patients 8 and less 1 breath every 3
  5 seconds
• Narcan (narcotic antagonist)
• 2 mg IVP if respiratory depression

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Glasgow Coma Scale Exercise

• Review the following 3 patients assessment
  findings
• Evaluate for their GCS
• Determine the best response and score the
  patients
• Best eye opening 1 - 4 points
• Best verbal response 1 5 points
• Best motor response 1 - 6 points
• Note GCS to be obtained on all patients!

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GCS Exercise 1

• You are assessing a 56 year-old patient
• The patient is unresponsive. Nothing happens when
  you call the patients name. when you pinch the
  patient, their eyes open, then close.
• When pinched, the patient says dont, stop and
  then is silent.
• When pinched, the patient pushes you away

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GCS Exercise 2

• Your patient is a 16 year-old male.
• Upon approaching, the patients eyes are open and
  they are looking around with an anxious look.
• They do not answer questions they groan if
  pinched.
• They do not follow commands. When touched, the
  patient grabs your arm and doesnt let go.

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GCS Exercise 3

• Your patient is an 8 month-old.
• Their eyes are closed. There is no response to
  pinching.
• When pinched, the patient groans weakly.
• When pinched, the patient tries to pull away or
  turn away from the evaluator.

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GCS Exercise Answers

• GCS 1 total 11
• Eye opening 2
• Verbal response 4
• Motor response 5
• GCS 2 total 11
• Eye opening 4
• Verbal response 2
• Motor response - 5

• GCS 3 total 7
• Eye opening 1
• Verbal response 2
• (groans to pain incomprehensible words)
• Motor response 4
• (withdraws to pain)

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Skill In-line Albuterol

• For Albuterol to have its bronchodilating
  effects, it must be delivered down into the lungs
• If the patient cant inhale it in, we have to
  push it in

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Normal use with corrugated tubing connected to
the T-piece
Kit connected to oxygen and run at 6 l/minute
(enough to create a mist). Nebulizer kept upright
at all times.
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In-line Albuterol

• Intubate the patient
• While waiting to intubate, can bag the
  Albuterol into the lungs via in-line set-up thru
  ambu mask
• Confirm placement in the usual manner
• visualization
• chest rise fall
• 5 point auscultation
• ETCO2 detector
• Evaluated after 6 breaths are delivered

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To adapt nebulizer to in-line use

• Remove mouthpiece from T-piece and replace with
  BVM
• Connect nebulizer to oxygen source

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• Corrugated tubing left in place on
  T-piece
• Clear adaptor placed on distal end of corrugated
  tubing
• Once intubated, clear adaptor connected to ETT

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• Albuterol will be effective if it gets into
  the bronchial system, not just into the back of
  the throat.
• The BVM helps push the Albuterol where it will
  do the most good.

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EKG Review Treatment
There is NO pulse!!!
6 second strip


The patient has no pulse!
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EKG Interpretation 1

• PEA with a rate over 60
• CPR
• Secure airway
• Search for causes (6 Hs 5 Ts)
• Establish IV/IO access
• Epinephrine 110,000 1 mg IVP/IO every 3-5
  minutes
• No Atropine rate over 60

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6 Hs

• Hypovolemia fluid challenge
• Hypoxia supplemented oxygen flow
• Hydrogen ion acidosis ventilate (breathe) for
  the patient
• Hyper/Hypokalemia electrolyte imbalance
• Hypothermia warm them up
• Hypoglycemia screen all unconscious/altered
  level of consciousness patients for glucose level

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5 Ts

• Toxins think little kids getting into the wrong
  places (ie purses, cabinets)
• Tamponade, cardiac
• Tension pneumothorax needle decompression
• Thrombosis, coronary
• Thrombosis, pulmonary (embolism)
• Trauma

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EKG Review Treatment
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EKG Interpretation 2

• Strip A complete heart block
• Strip B paced rhythm
• Unstable Type II and 3rd degree heart blocks
• Patient often unstable due to slow heart rate
• Begin TCP
• Rate 80/minute
• Sensitivity auto/demand
• Output lowest mA until capture

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Comfort Measures For TCP

• Valium 2 mg IVP slowly over 2 minutes
• May repeat 2 mg IVP every 2 minutes
• Maximum of 10 mg
• Can touch the patient and not receive shocks
• Its the patient that feels the electrical
  stimulation

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EKG Review Treatment
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EKG Interpretation 3

• VT wide complex, until proven otherwise, is VT
• 2 questions to ask for all tachycardias
• Question 1 is patient stable or unstable
• Evaluate LOC and B/P
• If you are not perfusing, you cannot maintain an
  adequate level of consciousness or blood pressure
• If unstable, prepare for immediate cardioversion
• If stable, ask question 2

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2nd Question To Ask if Stable Tachycardia

• Question 2 is complex (QRS) narrow or wide?
• Narrow think SVT
• Adenosine is drug of choice
• Wide think VT
• EMS choice between Amiodarone or Lidocaine
• Mixing the antidysrhythmics makes the heart more
  irritable
• Let the ED know which drug therapy was started

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• If stable VT
• Antidysrhythmic treatment
• Amiodarone 150 mg diluted in 100 ml D5W IVPB
• Draw up Amiodarone dose, add to 100 ml D5W IV bag
  and gently agitate to mix label the bag (drug,
  amount, time added)
• Run thru mini-drip tubing piggyback into the
  primary IV line
• Run over 10 minutes (rapid drip rate just below
  wide open)
• OR Lidocaine 0.75 mg/kg IVP x1
• Contact Medical Control for further orders

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EKG Review Treatment
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EKG Interpretation 4

• Sinus bradycardia
• If symptomatic/unstable (poor cardiac output with
  altered mental status and B/P
• Atropine 0.5 mg rapid IVP
• When theyre alive give them 0.5
• May repeat every 3-5 minutes to a max of 3 mg
• If ineffective begin TCP
• If TCP ineffective, treat per Cardiogenic Shock
• IV fluid challenge in 200 ml increments, Dopamine
  drip

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Wheres ST elevation?
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12 Lead Interpretation 1

• ST elevation in exercise 1
• V1 V3
• 12 lead obtained in field
• EMS to evaluate the 12 lead looking for patterns
  of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
• EMS to call in what they see fax the 12 lead

98
Wheres the ST elevation?
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12 Lead Interpretation 2

• ST elevation in exercise 2
• V2 V4
• 12 lead obtained in field
• EMS to evaluate the 12 lead looking for patterns
  of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
• EMS to call in what they see fax the 12 lead

100
Wheres the ST elevation?
101
12 Lead Interpretation 3

• ST elevation in exercise 3
• II, III, aVF
• 12 lead obtained in field
• EMS to evaluate the 12 lead looking for patterns
  of ST elevation
• I, aVL, V5, V6
• II, III, aVF
• Any contiguous V leads
• EMS to call in what they see fax the 12 lead

102
Bibliography

• Bledsoe, Porter, Cherry. Paramedic Care
  Principles Practices. 3rd Edition. Brady. 2009.
• Burrows-Hudson, S. Chronic Kidney Disease. AJN.
  Feb 2005. Vol 105, No2.
• http//en.wikipedia.org/wiki/Blood_pressure
• http//en.wikipedia.org/wiki/AVPU
• www.hospital-equipment.co.uk/images/taking-bl
• www.mayoclinic.com/health/hemodialysis/DA00078
• www.neuroexam.com/
• www.strokestrategyseo.ca/pdf_docs/neurological20a
  ssessment
• www.vascularweb.org/patients/NorthPoint/Dialysis_A
  ccess.html