Dialysis Emergencies
Objective: Recognize missed-dialysis crisis — pulmonary edema, hyperK ECG, bleeding fistula — and treat the cause, not a generic “sick renal” label.
Why This Is Hard
They missed dialysis and now cannot stand. Crews open fluids because the BP is 90. The lungs are already full and the ECG is a sine wave. AHA 2025 special circumstances: hyperkalemia is a reversible arrest cause. Volume overload is a CPAP problem, not a trauma line.
- Ask when they last dialyzed and whether the fistula is their only access.
- 12-lead. Wide and slow in this patient is hyperK until the receiving team says otherwise.
- Do not use the fistula or graft as a routine IV.
Field Rules (Education)
- HyperK: peaked T, wide QRS, sine wave, bradycardia, arrest. Calcium for ECG toxicity is protocol. See hyperK ECG.
- Volume overload: sit up, oxygen/CPAP if they protect the airway, destination that can dialyze.
- Bleeding access: direct pressure. Do not clamp a fistula for fun.
- Hypotension post-dialysis is a different picture (volume down) — history matters.
Field Pitfalls
- Using the fistula as an IV.
- Fluids wide open into missed-dialysis pulmonary edema.
- Amiodarone for a sine-wave bradycardia.
Practice
60-second drill
Partner: missed two runs, BP 88, wet, wide QRS. Fluid vs CPAP vs hyperK pathway.
Related: HyperK ECG, CHF.
Sources & Further Study
Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.
- NASEMSO National Model EMS Clinical Guidelines (2022) — U.S. EMS model language; protocol still wins
- AHA 2025 Part 10: Special Circumstances — hyperkalemia as a reversible arrest cause
- LITFL hyperkalemia ECG — teaching atlas — not a treatment guideline
Education only. Apply learning within your protocols and medical direction. This is not clinical care guidance.
Check Your Understanding
Street decisions from this lesson only. After you check, the key is highlighted. Education practice — not a certification exam.