Cases from the Field – September/October 2025 Edition

After your initial evaluation, some Provider Impressions that you might consider include:

• Alcohol Intoxication
• Allergic Reaction
• ALOC
• Behavioral/Psychiatric
• Carbon Monoxide
• Cardiac Dysrhythmia
• Chest Pain – Suspected Cardiac/STEMI
• Fever
• Hyperglycemia
• Hypoglycemia
• Overdose/Poisoning/Ingestion
• Seizure – Postictal
• Sepsis
• Shock
• Stroke

All the above listed Provider Impressions could be considered in this patient’s presentation. This patient has sudden onset ALOC with abnormal vital signs for an elderly person, including tachycardia, relative hypotension, tachypnea, and hypoxia. His history of ESRD on dialysis also indicates that he is at higher risk for several other conditions, such as spontaneous intracranial bleeding. More evaluation is necessary to hone down to a smaller list of potential Provider Impressions.

• Check a blood glucose level
• Perform an mLAPSS evaluation
• Place the patient in spinal motion restriction
• Place IV access alongside the fistula
• Obtain a 12-lead ECG
• Administer Narcan

Explanation: The correct answers are bolded above. Assessing blood glucose level, mLAPSS, level of alertness (GCS), and the ECG will assist you in modifying your differential diagnosis for this patient’s presentation while identifying immediate time-sensitive life-threatening etiologies such as hyperkalemia, stroke, and hypoglycemia. There is no evidence of traumatic injury requiring a C-Collar or other SMR. Narcan is indicated for opioid overdose with respiratory depression. Although this patient is hypoxic, his attempts to answer, his tachypnea, and normal pupil exam argue against severe opiate intoxication.

This patient should initially be managed with TP 1201 – Assessment and TP 1202 – General Medical while you try to determine a Provider Impression.

The following are your assessments & treatments:

• SpO2 92% on room air – you start the patient on O2 via NC.
• Fingerstick blood glucose is 98
• No obvious asymmetry/unilateral weakness – you determine mLAPSS as negative.
• 12-lead ECG: sinus tachycardia, no ST elevations or peaked T waves, QRS intervals <3 boxes (<0.10)
• GCS to be E4-V4-M6 = Total of 14
• With direct questioning, the patient’s wife denies that patient has history of drug or significant alcohol use or of psychiatric illness. She denies the presence of any drugs in the home. She denies any symptoms for herself, including headache (as you might see if the ALOC is due to CO exposure).

This narrows the list of possible Provider Impressions for this patient, as shown here.

• Alcohol Intoxication
• Allergic Reaction
• ALOC
• Behavioral/Psychiatric
• Carbon Monoxide
• Cardiac Dysrhythmia
• Chest Pain – STEMI
• Fever
• Hyperglycemia
• Hypoglycemia
• Overdose/Poisoning /Ingestion
• Seizure – Postictal
• Sepsis
• Shock
• Stroke – less likely

With this narrowed list of potential Provider Impressions, you decide to pursue a Provider Impression of ALOC and use TP 1229 – Altered Level of Consciousness for treatment. For altered mental status in this patient, there can be a wide range of pathologies including:

• Seizure
• Hyperkalemia
• Hypoxia
• Overdose
• Uremia
• Tumor
• Sepsis/Septic shock
• Air Embolism
• Stroke
• Subarachnoid Hemorrhage

While all the listed pathologies are possible for this patient with abrupt altered mental status, given his past medical history of ESRD, uremia and hyperkalemia should be heavily considered. He has missed his last dialysis session, and the accumulation of toxic metabolites may result in altered mental status known as uremic encephalopathy. Additionally, given the abrupt onset during dialysis, machine failures or dialysis related complications such as sepsis (risks for blood stream infections) and air embolism should be strongly considered.

You realize the patient is still plugged into the dialysis machine. Will you need to disconnect him? Can you disconnect him? You will need to obtain additional information. Looking around, you find contact information for a clinical dialysis nurse resting on the table by the tablet.

Patients on home hemodialysis are closely managed by a dialysis service. Home dialysis machines are highly complex; they need user interfaces that enable patients and their families, without formal medical training but with guidance from the dialysis service, to use the machines. The home hemodialysis machine should be accompanied by a tablet that automatically monitors and stores key information about the patient’s dialysis sessions.

On the tablet screen you will be able to see blood pressure and heart rate trends (often checked every 5-10 minutes while the patient is on dialysis) as well as the pressures on the venous and arterial side of the patient’s fistula throughout the recent session. Sudden drops in pressure may indicate fluid shifts or severe hypovolemia that may worsen hypotension and contribute to altered mental status. Often this may happen in dehydration or severe sepsis.

During home hemodialysis, patients connect themselves to a smaller version of the dialysis machine for a 3-4 hour session, up to 4 times per week. The patient must be careful when connecting themselves to ensure that no air enters the line, as this could create an air embolism. An air embolism occurs when air bubbles enter the bloodstream, blocking blood flow to vital organs like the brain, heart, or lungs. Symptoms of an air embolism vary on where the bubbles get stuck in the body, ranging from stroke-like symptoms and confusion to breathing problems, chest pain, and low blood pressure.

Where might you find additional information regarding the patient’s dialysis session? Check ALL that apply.

• The dialysis tablet blood pressure trend
• The dialysis tablet pressure graph
• The dialysis machine’s settings menu
• Evaluation of the dialysis lines
• Evaluation of dialysis machine motors

Explanation: The dialysis tablet hosts a wealth of information regarding a patient’s dialysis session, including blood the patient’s blood pressure and pressure in the tubing connecting the patient to the dialysis machine. Evaluation of the dialysis lines may identify air and suggest air embolism as an underlying pathology. The dialysis settings should be reserved for the patient or dialysis nurse to control and do not frequently provide useful information for an emergent evaluation. EMS personnel should not adjust these settings. Similarly, the evaluation of the mechanical motors which pump blood during dialysis do not help with narrowing a differential or evaluating a patient.

You astutely evaluate the patient’s dialysis tablet and lines. The patient’s blood pressure has been within normal limits, and he has only been mildly tachycardic for a short period, since he became altered. The spouse checks the tablet and notices there was an alarm for air in the line earlier in the session and see several bubbles of air within the dialysis lines. While your differential continues to remain broad, you are suspicious for an air embolism as the cause for this patient’s altered mental status. You contact base and they recommend transport to the nearest most accessible receiving facility. You start preparing the patient for transport and wonder how you may safely remove the patient from his dialysis machine. The wife states that she does not remember how to remove the patient from the machine as he has always done it himself.

1. Call your assigned base hospital
2. Contact the patient’s dialysis nurse
3. Review the dialysis tablet for a manual
4. Search for a dialysis manual in the house

Explanation: The correct answer is B – Contact the patient’s dialysis nurse. Contacting the dialysis nurse, whose number is frequently located next to the dialysis machine or nearby where the patient is sitting, is the most efficient and accurate way to safely remove the patient from their machine. They may be able to travel to help with removal or discuss the steps for removal for either a family member or for you to follow. The base hospital MICN/physician is unlikely to have experience with removal of dialysis lines and unlike your microwave, you probably won’t find a manual for the machine in the house. The dialysis tablet is a good resource to identify problems with dialysis; however, it does not contain instructions for connection/disconnection.

You call the dialysis nurse, and they discuss safe ways to remove the patient from a dialysis machine to facilitate transport. They clarify that the method for removal is different depending on the patient’s point of access. They send a video for you and the wife to review:

https://vimeo.com/1127299020/79fc5a81f2?share=copy&fl=sv&fe=ci

The family member uses this video to remember her previous training and safely removes the patient from the dialysis machine.  If no family member, nurse, or caretaker is available, you should contact base for the next best steps. You transport the patient to the emergency department and provide handoff.

Select ALL that apply

• Run time of the dialysis session
• Last complete dialysis session
• History of alarms
• Vital sign trend
• Finding of air in the lines
• Dialysis nurse’s contact information

Explanation: The correct answers are all of the above. Hand-off is a crucial time to pass along important information to facilitate the management of these patient’s moving forward. Any home hemodialysis patient should have a report of the run time of the dialysis session, their last completed dialysis session, a history of alarms and vital sign trends and your physical exam. The nurse’s contact information is helpful as not all emergency departments are equipped to manage these patients immediately. The make and model of the dialysis machine is not as essentially to managing their emergency.

The patient arrives to the ED where they rapidly move the patient into a left lateral decubitus position with head down. This is known as Durant position and may help prevent additional air embolisms from reaching the brain when suspicion for air embolism is very high. A broad workup for altered mental status is completed, and the patient is diagnosed with a venous air embolism. Hospital staff determine that the patient would benefit from hyperbaric therapy and coordinate transfer to a hyperbaric chamber. It is theorized to be similar to air embolism from dive injuries – the increased atmospheric pressure of hyperbaric therapy will shrink air bubbles by allowing them to move distally in vasculature, improve oxygen delivery and accelerates air resorption to reduce symptoms and limit progression. Following therapy, the patient’s mental status change resolves and he is discharged home with no persistent deficits.

• Los Angeles County has many patients receiving hemodialysis at home, and this number is steadily growing.
• Information you collect on scene, and from the dialysis nurse and review of the tablet, is crucial to the ED evaluation of home dialysis patients. EMS should bring the patient’s dialysis tablet and dialysis RN’s contact info with patients transported to the hospital.
• When assessing patients with altered mental status, proceed with your usual evaluation (including blood glucose, ECG, mLAPSS and LAMS) even while the patient is attached to the dialysis machine. mLAPSS positive? Transport to the most appropriate stroke receiving facility.
• Venous air embolism is a rare, but important, complication of dialysis that should be suspected when a patient suddenly develops altered mental status, chest pain, or dyspnea during dialysis. Look for air visible in the lines or if the machine alarms for air.
• Family members and their designees are encouraged to remove patients from their home device during an emergency. Work with family and assist them in the disconnection. If no contact is available, discuss with base.

Rope R, Ryan E, Weinhandl ED, Abra GE. Home-Based Dialysis: A Primer for the Internist. Annual Rev Med. 2024;75:205-217. doi:10.1146/annurev-med-050922-051415