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A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
A Sore Arm & A Sore Head
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A Sore Arm & A Sore Head

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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.

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