# No dialysis for 5 days



## BobBarker (Jan 2, 2018)

You get a call for a 62yo diabetic male who has not had dialysis for 5 days due to his fistula being clotted/dialysis staff unable to dialyze him despite multiple attempts. They inform you his last potassium was 7.0 (normal 3.5-5) the day before, so it has to be higher today. Blood pressure, breathing, and sp02 all within normal limits. Blood sugar is high at 340 mg/dl, but patient stated he had lunch and soda prior to being transported to dialysis.
Your patient does not complain of any chest pain. EKG shows borderline sinus bradychardia, left axis deviation and RBBB. Patients states he has RBBB for 3+ years.
Current medications are insulin, asprin, metoprolol, clonodine and atorvistatin.
You have a 24hr basic ER/hospital 10min away or a level 1 trauma center that has all capabilities 25min away.
EKG is attached. Go.


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## E tank (Jan 2, 2018)

He knows he's had a RBBB and for how long? That is one dialed in  patient!


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## BobBarker (Jan 2, 2018)

E tank said:


> He knows he's had a RBBB and for how long? That is one dialed in  patient!


Yes. Every year he says he gets an EKG and he had an echo cardiogram done 3 years ago. It's also pretty interesting how he has hyperkalemia yet he says he felt fine.


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## VentMonkey (Jan 2, 2018)

Sooo, a relatively stable patient for the time being?

Basic ALS workup, monitor and transport to the Level 1 that I presume has 24/7 dialysis capabilities. If anything changes en route enter appropriate protocol(s) for therapies required en route to the Level 1.

I don’t know that there’s much more to enforce here currently other than good old fashioned common sense, and good judgement. Really, what’s an extra 15 minutes going to matter?

Even if they did code, you should know your local area well enough to rendezvous with a fire station for extra hands if you needed them, or even another unit.


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## BobBarker (Jan 2, 2018)

VentMonkey said:


> Sooo, a relatively stable patient for the time being?
> 
> Basic ALS workup, monitor and transport to the Level 1 that I presume has 24/7 dialysis capabilities. If anything changes en route enter appropriate protocol(s) for therapies required en route to the Level 1.
> 
> ...


Fire Based EMS already . Treated with Sodium Bicarb, calcium chloride, glucose and insulin. Hospital later gave Kiexalyte while trying to find out what to do regarding the fistula.


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## VentMonkey (Jan 2, 2018)

Billy D said:


> Fire Based EMS already . Treated with Sodium Bicarb, calcium chloride, glucose and insulin.


Wait, so fire provided these therapies, or the receiving did? I’m a bit perplexed here.


Billy D said:


> Hospital later gave Kiexalyte while trying to find out what to do regarding the fistula.


That was my rationale here:


VentMonkey said:


> transport to the Level 1 that I presume has 24/7 dialysis capabilities.


Even if the cocktail was started prehospital, which quite honestly I wouldn’t just drop Bicarb, CaCl, and Albuterol on this patient just because I know they’re hyperkalemic regardless of them talking to me, and more importantly, currently presenting as stable.

Ensure you have patent venous access? Absolutely. Recall a second Iine may be warranted for the CaCl and Bicarb respectively? Sure. But aside from that, these temporary measures can hold off for a bit longer unless the receiving is that adamant that they be started posthaste. I don’t see many receivings being in that big of a rush without any other obvious signs of AMS/ instability present.

RRT is their definitive treatment, which they’d certainly get at the tertiary ED. If anything, your scenario serves as a good reminder that critical thinking is quite literally thinking your way through things, and less about reacting with knee-jerk reflexes.


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## DrParasite (Jan 2, 2018)

Billy D said:


> Fire Based EMS already . Treated with Sodium Bicarb, calcium chloride, glucose and insulin.


why are you giving glucose when his BGL is already 340?


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## NomadicMedic (Jan 2, 2018)

Put on cot, drive to hospital with dialysis.
Write PCR. Have lunch.

I wouldn’t have started messing around with bicarb and Calcium until I had labs. He was asymptotic.


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## NomadicMedic (Jan 2, 2018)

DrParasite said:


> why are you giving glucose when his BGL is already 340?



CBADIF

Calcium, bicarb, albuterol, dextrose, insulin and Lasix is the standard cocktail for hyperk. You actually should be giving the dextrose and insulin concurrently.

But really, this guy needs dialysis.


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## VentMonkey (Jan 2, 2018)

DrParasite said:


> why are you giving glucose when his BGL is already 340?


The combination of Insulin and glucose will promote glucose uptake at the cellular level. All temporary measures until RRT can be effectively performed.

A slug of D50 with this patient’s BGL would most likely be an insignificant amount, especially along with the Insulin to counterbalance its typical response.


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## BobBarker (Jan 2, 2018)

VentMonkey said:


> Wait, so fire provided these therapies, or the receiving did? I’m a bit perplexed here.
> 
> That was my rationale here:
> 
> ...


I should have been more clear, the dialysis center was the one who treated him with this prior to us getting there. I wanted to write the scenario as if he was untreated to see if you as a pre-hospital provider would have done the same treatment or left it up to the hospital. This specific dialysis center is big and the medical director is usually in house. This time, the Dr. was at the bedside ordering medicines prior to our arrival. We all know the cocktail of medicines he got is temporary, and he needs to get to the hospital to get his fistula fixed or a catheter put in to dialyze him.


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## DrParasite (Jan 2, 2018)

VentMonkey said:


> The combination of Insulin and glucose will promote glucose uptake at the cellular level. All temporary measures until RRT can be effectively performed.
> 
> A slug of D50 with this patient’s BGL would most likely be an insignificant amount, especially along with the Insulin to counterbalance its typical response.


That's actually pretty interesting, I didn't know that.... 

I don't know many trucks that carry insulin on their trucks either, but it's still good to know.


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## VFlutter (Jan 2, 2018)

This guy doesn't really need any acute treatment other then Kayexalate and transport to which ever hospital placed his fistula.


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## E tank (Jan 2, 2018)

A K of 7 in a guy like this, I'd watch and bring him somewhere he could get a dialysis catheter placed and RRT. Having said that, a HD center has the capacity to run a stat potassium in the time it takes to get a set of vitals so if that came back pushing above 7.3-7.5 I think I'd treat him with what I had available to me. 

Even though he was asymptomatic and even though his ekg was reassuring, those are no guarantees that he wouldn't go sideways suddenly somewhere between the time you loaded him and the time the ER staff got around to getting the K down (after measuring it themselves). 

You lose nothing by giving an amp of cacl and if it buys the patient a little time, it's a win-win. Sugar and insulin act within minutes to drop serum K, kayexelate takes hours to days and he'd probably get dialysis before it had a chance to work. But it does actually eliminates systemic potassium as opposed D50/insulin which just temporizes the situation by "hiding" the potassium intracellularly.

I wouldn't bother with the bicarb.


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## BobBarker (Jan 2, 2018)

Followed up with the hospital. 7.9 potassium upon arrival. Kaexalyte and albuterol given in ER, transferred to ICU and AMA'd out the next night after a successful dialysis treatment and an appointment with the vascular surgeon. Apparently, the fistula had a clot that was treated. Nurse said the Kaexalyte enema along with the other treatments dropped the potassium from 7.9 at admission to 5.4 twelve hours later, before he was finally dialyzed. Pretty cool stuff.


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## medichopeful (Jan 3, 2018)

Monitor and transport to the Level 1 non-emergently.  I wouldn't really go messing around with fixing his lytes en route unless something changes.


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## Brandon O (Jan 3, 2018)

VentMonkey said:


> Even if the cocktail was started prehospital, which quite honestly I wouldn’t just drop Bicarb, CaCl, and Albuterol on this patient just because I know they’re hyperkalemic regardless of them talking to me, and more importantly, currently presenting as stable./QUOTE]
> 
> I would. They can go bad fast. These renal patients sometimes tolerate hyperkalemia better than you or I, and a totally normal ECG can be reassuring (but this one isn't), but a basic cocktail is cheap and safe, so there's little reason not to temporize him. It will be a while until someone comes up with a solution for clearing his K (fixing his fistula, a new line, pooping it out, whatever).


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## Carlos Danger (Jan 3, 2018)

I think there’s little risk and possibly significant benefit in an amp of bicarb and letting him puff on an albuterol nebulizer, and insulin if you have it.

I don’t think you’d be wrong to give some calcium, or wrong to wait on that and watch the EKG closely and see if the other therapies help.


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## NomadicMedic (Jan 3, 2018)

I’m curious who has prehospital protocols for Calcium, bicarb, Dextrose and albuterol for an asymptomatic hyperK+. 

I’d bet that it’s Med Control orders for most (quiet Texans!) and the doc would say, “eh, just bring em in”.


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## Peak (Jan 3, 2018)

If I got this as a 911 call it would mostly be a straightforward ALS transport. Monitor 3 lead. BGL recheck 30 and 60 minutes after insulin administration (some patients can have a more profound reaction to IV insulin, even if it was only 10 units). Transport to a facility which has IR and HD/CRRT, they may need to place a HD catheter until they get someone in to revise his fistula.

As a scenario where the patient hasn't received meds already I would be hesitant to start treatment in the bus on an asymptomatic patient, especially if we have a short transport.


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## StCEMT (Jan 3, 2018)

IVx2, 12 lead, ******** with the patient while I write my report. I'd consider asking if they would like any of the standard treatments started while I had all that time, but I would not be in any rush to do anymore than have things accessable and a nice conversation.


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