Your SlideShare is downloading. ×
  • Like
A Sore Arm & A Sore Head
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Now you can save presentations on your phone or tablet

Available for both IPhone and Android

Text the download link to your phone

Standard text messaging rates apply

A Sore Arm & A Sore Head

  • 731 views
Published

 

Published in Health & Medicine
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
731
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
1
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Acute Renal Failure
  • 2. Acute Renal Failure is Common (and not very nice … .)
    • BMJ    2006;333:786-790   (14   October) Rachel Hilton.
    • A rapid fall in glomerular filtration rate, clinically manifest as an abrupt and sustained rise in urea and creatinine
    • Key points include:
    • 1% of acute admissions dues to ARF, ARF complicates 7% of admissions.
    • If dialysis needed mortality about 50%
    • Previous studies have shown under-referral 1
    • Nephrology advice may improve outcomes! 2
  • 3. Refs
    • Khan IH, Catto GR, Edward N, Macleod AM. Acute renal failure: factors influencing nephrology referral and outcome. QJM 1997;90: 781-5.
    • Star RA. Treatment of acute renal failure. Kidney Int 1998;54: 1817-31
  • 4. A Sore Arm & A Sore Head
    • Mr LB, aged 28
    • Presented to A&E c/o sore swollen arm.
    • IVDU – has been speedballing
    • Last memory Wednesday night – woke Saturday Morning, attended A&E
    • A&E documented swollen left arm and area of pressure on elbow, with surrounding redness
    • S/B orthopaedics:
    • Dx Olecranon Bursitis
    • Admitted to CLDU for IV Abx
  • 5. A Sore Arm & A Sore Head
    • Minimal past history obtained.
    • Creatinine elevated Urea 20.3 creatinine 259
    • CRP 21, WCC 14.1
    • Referred to medics who reviewed Saturday night
    • Though to be dehydrated plus cellulitis – IVI commenced overnight.
    • Seen by consultant following day & referred to Renal SpR
  • 6. A Sore Arm & A Sore Head
    • Long history of IVDU
    • Left Prison 3/52 ago & only just started using drugs again.
    • Known Hep C positive but “ didn ’ t mention it ” to other teams!
    • Past history of epilepsy – last fit 2 weeks earlier when tablets “ ran out ”
    • Actually complaining of pain in left arm and leg, plus numbness in hand
    • Unkempt, bruising left ear and eye (old)
    • Swollen oedematous left arm & leg with multiple pressure areas and grazes
    • Chest clear
    • Abdo SNT
    • HS1 + 2 + ESM
    • Distal numbness left hand not conforming to a specific dermatome/ nerve distribution.
  • 7. A Sore Arm & A Sore Head
    • ECG lost (this is important)
    • CXR not done therefore requested
    • Arm X-rays NAD
    • Urine Dip Blood +++, Pro +
    • Blood cultures negative
    • Rhabdomyolysis +/- compartment syndrome in left hand
    • Renal impairment secondary to cardiovascular collapse or vessel problems (cocaine)
    • Endocarditis (Murmur plus skin changes)
    • Hep C Associated?
  • 8. Results
    • CK 22087
    • ECHO – large anterior-septal infarct with hypokinesia & left ventricular thrombus
    • ECGs found – changes in keeping with above!!!
    • CK Mass 10 (normal 1-5)
    • Trop T 1.22
    • No myoglobin achieved!
    • Renal & Abdo USS normal, as were arm & leg dopplers
    • Hb 16.6, WCC 14.1, Pts 108
    • Na 137. K 4.9, Ur 20.3 Creat 259
    • CRP 21
    • ALT 1009, LDH 2936,
    • Bili 16, ALP 125, CCa 2.21
  • 9. Results continued … .
    • ANCA, ANA, GBM, Cardiolipin negative
    • Complement normal
    • D-dimers raised, clotting normal. Hep B & C positive
    • HIV not tested
    • Cryoglubulins not tested
    • Nerve conduction studies were planned
    • Renal function improved with rehydration & bicarbonate
    • Warfarin commenced & ortho asked to review re: ?compartment syndrome
  • 10. Progress
    • Patient went on to be extremely difficult to manage, with needles secreted about his person & behaviour posing a risk to staff and other patients
    • Unfortunately behaviour meant he was discharged under Zero Tolerance rules.
    • Last bloods: urea 5.3, creat 59, ALT 131, CK 560, Hb 10.9, pts 643
  • 11. Cocaine, Ischaemia & Renal Failure
    • Cocaine has been implicated as a trigger in Myocardial Infarction even in patients with normal coronaries 1
    • Cocaine may cause Rhabdomyolysis even in the absence of muscle pain and signs, or pressure injury. 2
    • Rhabdomyolysis has been considered to be related to a neuroleptic-malignant type syndrome – with agitated excitement, hyperthermia & rhabdomyolsis. 3
    • Renal Infarction has also been reported with cocaine use.
  • 12. Refs:
    • Murray A, Mittel M et al, Circulation. 1999;99:2737-2741
    • Welch R, Todd K, Krause G, Ann Emerg Med . 1991 Feb;20(2):154-7.
    • Dara M, Kakkouras L , Acta Neurol Scand . 1995 Aug;92(2):161-5.