Adult Medical Emergency Handbook - Scottish Intensive Care Society

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• Fluid overload with pulmonary oedema, refractory to diuretics.
• Severe metabolic acidosis.
• Pericarditis
• Renal replacement also indicated if urea and/or creatinine are
markedly elevated. Discuss with the renal registrar.
Call Renal Registrar page #6394 in RIE, ICU in WGH or SJH
- seek advice early.
INVESTIGATIONS
• U&E (including total CO 2 ), creatinine, glucose, FBC, clotting
screen, group, screen and save, blood cultures.
• Plasma CK and urinary myoglobin (if available).
• ABGs
• Blood film for red cell fragments.
• Ca, PO 4 , LFTs, albumin.
• Urate
• Glomerulonephritis screen where appropriate.
• Viral screen.
• Urinalysis
• Urine sodium and osmolality: interpretation is complicated by prior
administration of IV fluids or diuretics.
• Urgent ultrasound of kidneys: size, number, obstruction, aorta.
All patients with acute renal failure should have USS of renal
tract. Timing will depend on clinical presentation.
FURTHER MANAGEMENT
• If oliguria persists or biochemistry worsens renal replacement
therapy (haemodialysis or haemofiltration) may be required:
discuss with the Renal Registrar RIE or ICU in WGH/SJH.
• Scrutinise the notes, drug charts and review the history.
• Fully examine the patient.
• Look for infection and treat it.
Remember rhabdomyolysis. Muscle signs and symptoms are only
seen in 50%, and myoglobin is absent from urine in about 30%.
Causes include trauma, burns, compartment syndrome, epilepsy,
drugs (including self-poisoning), coma with hypotension, falls and
ischaemic limbs.
adult medical emergencies handbook | NHS LOTHIAN: UNIVERSITY HOSPITALS DIVISION | 2009/11
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