Dialysis Emergencies
Objective: Recognize a missed-dialysis emergency: wet lungs, an ECG that fits high potassium, or a bleeding dialysis access. Treat that cause. Do not call every one of these a generic sick kidney patient.
Why this matters
A patient misses dialysis and can no longer stand. The lungs may already be full of fluid. The ECG may show a sine wave, a wide, slow, wavy rhythm from high potassium. Crews sometimes open fluids because the blood pressure is 90. Do not do that when the lungs are wet. High potassium is a reversible cause of cardiac arrest. Fluid overload is a CPAP problem, not a trauma fluid bolus.
- Ask when they last dialyzed. Ask whether the fistula, the dialysis access under the skin, is their only access.
- Get a 12-lead. A wide, slow rhythm in this patient is high potassium until the receiving team says otherwise.
- Do not use the fistula or the graft as a routine IV.
Clinical sequence
- Ask the last dialysis day and whether the fistula is the only access.
- Get a 12-lead. Treat a wide, slow rhythm as high potassium until proven otherwise.
- Get IV access somewhere else. Do not stick the fistula or the graft for a routine line.
- If the lungs are wet, sit them up first. Give oxygen or CPAP if they protect the airway. Do not run a large fluid bolus into missed-dialysis fluid in the lungs.
Teaching points
- High potassium. Peaked T waves, a wide QRS, a sine wave, a slow heart rate, and arrest are the ECG pattern. Calcium for those ECG changes is a protocol drug. See the hyperkalemia ECG lesson.
- Fluid overload. Sit them up. Use oxygen or CPAP if they protect the airway. Go to a hospital that can dialyze. Do not flood wet lungs.
- Bleeding access. Hold direct pressure. Do not clamp a fistula without a reason.
- Low blood pressure right after dialysis is different. That patient may be low on fluid. The history tells you which problem you have. Do not treat every dialysis patient the same way.
Common errors
- Using the fistula as a routine IV.
- Running a large fluid bolus into wet lungs after missed dialysis.
- Giving amiodarone for a sine-wave slow rhythm instead of treating high potassium.
Practice
One-minute check
They missed two dialysis sessions. Blood pressure is 88, the lungs are wet, and the QRS is wide. Choose among fluids, CPAP, and a high-potassium pathway, and say why.
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; your protocol still decides care
- 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
Questions drawn only from this lesson. After you check, the key is highlighted. Education practice — not a certification exam.