What service should a patient with end-stage renal disease (ESRD) on biweekly dialysis be directed to after a fall and loss of consciousness?

Triage Management for Dialysis Patient with Fall and Loss of Consciousness

A patient with end-stage renal disease (ESRD) on biweekly dialysis who has fallen and lost consciousness should be immediately triaged to emergency/urgent care services with nephrology consultation. 1

Initial Assessment and Triage Priorities

• Patients with loss of consciousness (TLoC) require immediate evaluation for potentially life-threatening conditions, especially when complicated by ESRD 2
• Falling level of consciousness in a dialysis patient requires urgent assessment for airway protection, ventilatory support, management of raised intracranial pressure, and correction of electrolyte imbalances 2
• ESRD patients have higher risk for adverse outcomes after falls due to electrolyte abnormalities, medication effects, and comorbidities 2, 1

Critical Considerations for ESRD Patients with TLoC

• Evaluate for absolute indications for urgent dialysis including:

  • Severe hyperkalemia (>6.5 mEq/L) with ECG changes 1
  • Volume overload with pulmonary edema 1
  • Severe metabolic acidosis (pH <7.2) 1
  • Uremic encephalopathy with altered mental status 1

• Monitor for signs of:

  • Electrolyte abnormalities, especially potassium, which can cause cardiac arrhythmias 1
  • Fluid overload that may have contributed to the fall 1
  • Uremic encephalopathy that may present with confusion or altered consciousness 1

Diagnostic Approach

• All patients with TLoC should receive electrocardiography to assess for cardiac causes 2
• Evaluate for suspected cardiac causes of TLoC, which are common in ESRD patients and require specialist cardiovascular assessment 2
• Consider neurological causes including seizures, which may require specialist neurological assessment 2
• Assess for orthostatic hypotension, which is common in dialysis patients and can lead to falls 2, 1

Special Considerations for ESRD Patients

• ESRD patients are at higher risk for medication-related problems during care transitions, requiring careful medication reconciliation 2
• Patients over 65 years with ESRD may experience shock with SBP <110 mmHg and are at high risk for severe injury even from low-impact falls 2
• Fluid resuscitation in ESRD patients with sepsis should be approached cautiously but not withheld if needed 3
• Recognize that dialysis patients may need dose adjustments for medications commonly used in emergency settings 2

Recommended Triage Pathway

1. Initial stabilization: Assess airway, breathing, circulation with continuous cardiac monitoring 1
2. Emergency department evaluation: Complete workup including electrolytes, BUN/creatinine, ECG, and neurological assessment 2, 1
3. Urgent nephrology consultation: Required for all ESRD patients with TLoC to manage dialysis-specific issues 2, 1
4. Consider urgent dialysis: If hyperkalemia, fluid overload, acidosis, or uremic encephalopathy is present 1
5. Appropriate specialist referral: Based on suspected etiology (cardiology, neurology) 2

Common Pitfalls to Avoid

• Delaying dialysis in the presence of life-threatening complications such as hyperkalemia or pulmonary edema 1
• Failing to adjust medication doses for renal function, which can lead to adverse events 2
• Overlooking medication reconciliation at care transitions, which is essential for ESRD patients 2
• Assuming TLoC is solely due to ESRD without investigating cardiac or neurological causes 2

By following this approach, you can ensure appropriate triage and management of ESRD patients with falls and loss of consciousness, minimizing morbidity and mortality in this high-risk population.