# Hyperkalemia Call Review



## NPO (Jan 1, 2017)

I'll start off by saying I'm a fairly new paramedic, so this was quite a finding for me, and I thought it was an interesting call. Hopefully someone else will enjoy it.

Responded for an unconcious person. Found a 32 year old male concious on his bed. Reported to have had a syncopal episode and is complaining of SOB for the past day. Room air SPO2 was 66% per the BLS crew on scene who applied a NRB. 

HX: mi, Htn, DM, CHF, ESRD, dialysis

Vitals: 
Bp: 130/80
Hr: 80
Spo2: 90% on 15lpm
BGL: 30

Upon placing the patient on the monitor I noticed the rhythm below. I sent a 12-lead to the hospital. EKG indicated AMI, but I consulted online medical control and told them I believed it to be hyperkalemia, and they concured. They have orders for Bicarb. I never got a line, so I couldn't give meds, but I gave oral glucose. The hospital gave insulin, d50 albuterol, bicarb and calcium gluconate. We all watched him convert to sinus tach. 

It was a good call, even though I didn't end up doing much.












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## VentMonkey (Jan 1, 2017)

NPO said:


> The hospital gave insulin, d50 albuterol, bicarb and calcium gluconate. We all watched him convert to sinus tach.


This is the standard course for severely hyperkalemic ESRD and/ or diabetics; good learning experience it sounds like though. 

Oftentimes they're extremely sick, and I would be hard pressed not to ask for Calcium Chloride order over bicarb.


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## NPO (Jan 1, 2017)

VentMonkey said:


> This is the standard course for severely hyperkalemic ESRD and/ or diabetics; good learning experience it sounds like though.
> 
> Oftentimes they're extremely sick, and I would be hard pressed not to ask for Calcium Chloride order over bicarb.


Yeah, I'm frustrated that I was unable to get vascular access to get treatment started, although I could've started albuterol. 

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## VentMonkey (Jan 1, 2017)

NPO said:


> Yeah, I'm frustrated that I was unable to get vascular access to get treatment started, although I could've started albuterol.


Eh, TMK Albuterol is a farther down line/ secondary treatment. Typically, these patients are best served with CaCl- as their primary therapy. That's the true "life-saving" drug of choice, though I hardly doubt it would have made a difference prior to ED delivery. I wouldn't fret too much about vascular access, unless they were still unconscious/ unresponsive.


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## PotatoMedic (Jan 1, 2017)

Honestly I'm trying to read the strip.  Almost looks like a slow vtach.  But looking at it closer I see the p waves.  I keep forgetting that with bad hyper k at some point the qrs gets all buggered up.


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## VentMonkey (Jan 1, 2017)

FireWA1 said:


> Honestly I'm trying to read the strip.  Almost looks like a slow vtach.  But looking at it closer I see the p waves.  I keep forgetting that with bad hyper k at some point the qrs gets all buggered up.


Yes, and can often precede lethal arrhythmias, hence the importance of Calcium Chloride/ Gluconate over other meds.


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## NPO (Jan 1, 2017)

Oh, and he had a cardiac EF of 10% not that it's relevant, but just more to the history. 

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## StCEMT (Jan 1, 2017)

How was this dude feeling with a bgl of 30?


VentMonkey said:


> Eh, TMK Albuterol is a farther down line/ secondary treatment. Typically, these patients are best served with CaCl- as their primary therapy. That's the true "life-saving" drug of choice, though I hardly doubt it would have made a difference prior to ED delivery. I wouldn't fret too much about vascular access, unless they were still unconscious/ unresponsive.


Aren't the effects of albuterol in these cases pretty minimal realistically?


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## NPO (Jan 1, 2017)

StCEMT said:


> How was this dude feeling with a bgl of 30?
> 
> Aren't the effects of albuterol in these cases pretty minimal realistically?


Alert, and oriented by the strictest of definitions. He was a little confused and somewhat noncompliant with commands and treatments. He eventually became weak and needed stimuli to stay awake. 

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## VentMonkey (Jan 1, 2017)

StCEMT said:


> How was this dude feeling with a bgl of 30?
> 
> Aren't the effects of albuterol in these cases pretty minimal realistically?


I've seen people range anywhere from mega altered to normal with BGL's less than 30 mg/ dl, but I digress...

Yes, TMK it (albuterol) augments cellular stabilization and/ or their severe chemical imbalance.


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## StCEMT (Jan 1, 2017)

Yea, I know people can be fine down there, I just haven't seen it. Last person I saw that low was out. 

Might be a little cursory reading for tomorrow. Never did really understand how it helped, I just knew it was a down the line treatment.

Cool to see the EKG for it though, I haven't seen it like this in....hell probably close a year. Back when I was a clueless medic student. @VentMonkey, once the QRS starts to prolong, is there any general rule of thumb as to how long they will maintain that without their heart just saying "nope, no more"? Wondering about differentiating between the "Ok, I got a minute" and "****, minutes gone" based on how long it has gotten?


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## VentMonkey (Jan 1, 2017)

StCEMT said:


> @VentMonkey[/USER], once the QRS starts to prolong, is there any general rule of thumb as to how long they will maintain that without their heart just saying "nope, no more"? Wondering about differentiating between the "Ok, I got a minute" and "****, minutes gone" based on how long it has gotten?


I don't know that there's a time frame per se, but that being said, for me? ESRD, missed dialysis, and wide funky QRS means it's time to ask for CaCl- orders before all else. 

This is another patient category that you may want to place on the pads as well. IV or not, prepare for the worst, and expect the least.


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## StCEMT (Jan 1, 2017)

VentMonkey said:


> I don't know that there's a time frame per se, but that being said, for me? ESRD, missed dialysis, and wide funky QRS means it's time to ask for CaCl- orders before all else.
> 
> This is another patient category that you may want to place on the pads as well. IV or not, prepare for the worst, and expect the least.


Agreed on all of the above, I'd be on the phone asap. Like those spaced 12 leads, I've never seen this particular thing progress. Curiosity.


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## VentMonkey (Jan 1, 2017)

StCEMT said:


> Agreed on all of the above, I'd be on the phone asap. Like those spaced 12 leads, I've never seen this particular thing progress. Curiosity.


They're precursors to ventricular arrhythmias. Google "R on T phenomenon", and "stone heart in an electrolyte imbalance". They should yield results and articles way beyond my knowledge.


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## Nova1300 (Jan 1, 2017)

There are only 2 ways to effectively get potassium out of the plasma.  You can pee it out with diuretics, or you remove it with dialysis.  

The remainer of the treatment algorithm serves only to temporize until you can do one of those two things.  

CaCl will stabilize the cardiac membrane.  Catecholamines (including albuterol) will cause an intercellular shift of potassium,  pushing it out of plasma and into the cells.  But the total body potassium load is unchanged, and eventually this process will reverse and the potassium will leak back into the plasma.  

Alkalosis will also cause an intercellular shift of potassium.  This can be accomplished with either bicarb or hyperventilation.  However, like catecholamines, is only a temporizing measure and will not fix the problem.  

Diluting the plasma potassium with fluids will also help.  But again, total body potassium has not changed, you have just temporized.


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## NPO (Jan 1, 2017)

Follow-up:
Patient is in ICU. They were unable to CT because they couldn't lay him flat. His potassium was 8.9. He received emergency dialysis and is currently on levophed. 

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## VentMonkey (Jan 1, 2017)

NPO said:


> Follow-up:
> Patient is in ICU. They were unable to CT because they couldn't lay him flat. *His potassium was 8.9*. He received emergency dialysis and is currently on levophed.


Sounds like the patient is fortunate to be alive. These are the types of patients that truly are sick, and most may write as "not as exciting as a cardiac arrest, or a 'cool' trauma".

Thanks for sharing, @NPO.


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## NPO (Jan 1, 2017)

VentMonkey said:


> Sounds like the patient is fortunate to be alive. These are the types of patients that truly are sick, and most may write as "not as exciting as a cardiac arrest, or a 'cool' trauma".
> 
> Thanks for sharing, @NPO.


I find way more "excitement" our of a critical medical aid like this one.

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## Brandon O (Jan 1, 2017)

Nova1300 said:


> There are only 2 ways to effectively get potassium out of the plasma.  You can pee it out with diuretics, or you remove it with dialysis.



Or you can make them poop it out. How to accomplish this is a bit controversial. Traditionally kayexalate, but now some don't like that, so you can use lactulose or another osmotic laxative.

For the OP: ESRD patient with cardiac issues = always worry about hyperkalemia. I think an IO would have been appropriate; they could have coded.


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## VentMonkey (Jan 1, 2017)

Brandon O said:


> Or you can make them poop it out. How to accomplish *this is a bit controversial*. Traditionally kayexalate, but now some don't like that, so you can use lactulose or another osmotic laxative.
> 
> For the OP: ESRD patient with cardiac issues = always worry about hyperkalemia. I think an IO would have been appropriate; they could have coded.


@Brandon O, is the controversy due to the metabolic disturbance it poses?

Also, in the ops defense, our ground crews don't have EZ-IO, and still use jamshidis (yep, we all know...), so the patient would have to be pretty obtunded with a 40 mg lidocaine flushed in ASAP. 

There are always jugulars as well, but again, I wasn't there, nor will I quarterback his work.


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## MackTheKnife (Jan 1, 2017)

NPO said:


> Yeah, I'm frustrated that I was unable to get vascular access to get treatment started, although I could've started albuterol.
> 
> Sent from my SM-G935T using Tapatalk


What was the specific problem with IV access (other than crappy veins)? No access to an EJ or not allowed by protocol? IO?, Legs?  Just curious.


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## MackTheKnife (Jan 1, 2017)

NPO said:


> Oh, and he had a cardiac EF of 10% not that it's relevant, but just more to the history.
> 
> Sent from my SM-G935T using Tapatalk


10%? I get a few of those on my floor. And they're conscious.


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## Brandon O (Jan 1, 2017)

VentMonkey said:


> @Brandon O, is the controversy due to the metabolic disturbance it poses?



No data supporting its efficacy (kayexelate), some suggesting lack of it, and (most importantly) some suggesting a not-insignificant risk of bowel necrosis.

I was taught to use lactulose instead, which has become quite the all-purpose laxative for some people -- good for hyperammonemia, hyperkalemia, constipation...



> There are always jugulars as well, but again, I wasn't there, nor will I quarterback his work.



Sure, no criticism, just trying to frame this with the right sort of urgency and give permission to do whatever's necessary and permitted. Hyperkalemia with ECG changes like this is Big Sick.


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## MackTheKnife (Jan 1, 2017)

Nova1300 said:


> There are only 2 ways to effectively get potassium out of the plasma.  You can pee it out with diuretics, or you remove it with dialysis.
> 
> The remainer of the treatment algorithm serves only to temporize until you can do one of those two things.
> 
> ...


Insulin and Bicarb works effectively, but you don't carry insulin, do you?


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## VentMonkey (Jan 1, 2017)

Brandon O said:


> Sure, no criticism, just trying to frame this with the right sort of urgency and give permission to do whatever's necessary and permitted. Hyperkalemia with ECG changes like this is Big Sick.


No doubt. I wasn't implying you were armchair QB-ing either. I meant me specifically not being there. I agree about these patients being sick sick. What with the widened QRS, amongst other signs and symptoms presented in-field.

I was glad he shared it, as this is an excellent learning experience and refresher for many of us not in the hospital setting.


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## NPO (Jan 1, 2017)

MackTheKnife said:


> What was the specific problem with IV access (other than crappy veins)? No access to an EJ or not allowed by protocol? IO?, Legs?  Just curious.


I attempted a single IV en route, but he had no access. I looked for an EJ, but I couldn't lay him down due to his reapritory status, and he had a large neck, and I couldn't find anything. 

I agree, an IO was 100% appropriate, and I'm kicking myself for not doing it. It simply slipped my mind until too late into transport and we were already pulling up to the ER. In retrospect I should have moved straight to IO. His legs were also quite large, but I think I would've gotten it.

@VentMonkey he was altered anough to take the IO with Lido, and I'm wishing I wouldve.

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## StCEMT (Jan 1, 2017)

VentMonkey said:


> Sounds like the patient is fortunate to be alive. These are the types of patients that truly are sick, and most may write as "not as exciting as a cardiac arrest, or a 'cool' trauma".
> 
> Thanks for sharing, @NPO.


I mean while a successfully ran arrest is exciting, its more exciting to actually have to piece something together and properly manage it. ACLS is easy, just follow the steps. These folks require thinking. Always cool to have that lightbulb moment.


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## Carlos Danger (Jan 1, 2017)

Good job, OP. Sounds like you did all you could within the limitations of not being able to get a line.

Some IM epi could potentially be helpful in other cases like this. It's a gamble in a patient with such a sick heart, though.


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## VentMonkey (Jan 1, 2017)

You know, it definitely is refreshing to see newer paramedics that are still fascinated with the medicine, and pathophys aspects of this job.

How often do we see, or hear "Reaper Racers" on here who buy completely into the wrong idea of what it is to be not only a paramedic, but almost seemingly ignore how to strive to be sound clinicians as well? 

To add to this, to come on the forum and share their stories does show a sense of humility, as opposed to others who are almost instantaneously "upset" when called out by some of the more clinically, and life experienced forum members than themselves.

Also, some good discussions going on throughout this forum for the New Year, keep it up all.


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## NPO (Jan 2, 2017)

Remi said:


> Good job, OP. Sounds like you did all you could within the limitations of not being able to get a line.
> 
> Some IM epi could potentially be helpful in other cases like this. It's a gamble in a patient with such a sick heart, though.


Thank you. What are you considering Epi as treatment for? 

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## zzyzx (Jan 4, 2017)

When you see a sine-wave rhythm like this, it means the patient is close to coding. So yes, absolutely, an IO was indicated in order to give calcium chloride, but as the OP has said, he is already kicking himself for not having done so. A potassium of 8.9 is scary.

Bicarb is an old-school treatment that is no longer the standard of care for hyperkalemia, but old practices die hard.

Albuterol and insulin with dextrose are effective ways to shift the potassium across the cell membrane. Total body potassium is not changed.

Kayecalate works incredibly well at making the patient poop. Not so great for the nurse who's taking care of him, nor for actually lowering the potassium level.

Basically all these treatments are just temporizing measures to get the patient to dialysis.


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## Summit (Jan 4, 2017)

zzyzx said:


> When you see a sine-wave rhythm like this, it means the patient is close to coding. So yes, absolutely, an IO was indicated in order to give calcium chloride, but as the OP has said, he is already kicking himself for not having done so. A potassium of 8.9 is scary.
> 
> Bicarb is an old-school treatment that is no longer the standard of care for hyperkalemia, but old practices die hard.
> 
> ...


Agree with all of this.

And a dialysis patient why would you bother with kay or lactulose... even if they worked as advertised, they don't advertise working fast.  You can dialyze them back to normal limits far faster without any enemas and their complications. This patient already has dialysis access!

Save the lactulose for the hyperammonemia/hepatic encephalopathy and the kayex for the short list of situations where you wouldn't want to dialyze but are desperate to pharmacologically drive excretion.


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## hometownmedic5 (Jan 4, 2017)

StCEMT said:


> I mean while a successfully ran arrest is exciting, its more exciting to actually have to piece something together and properly manage it. ACLS is easy, just follow the steps. These folks require thinking. Always cool to have that lightbulb moment.



I truly don't get how anybody finds excitement in a cardiac arrest. For sure, you do a lot of skills in a short period of time. No doubt about that; but if you look beyond the chaos, that's all it is. A skills lab. 

The overwhelming majority of the time, a patient in cardiac arrest is not long for this world. Whether they stay dead in the living room, die in the box or the ED, or the ICU a week later; chances are very close to absolute they are going to die. Once you realize that, most likely, you're just flogging a dead horse in case your patient is in the 2 or 3 percent that are going to make it, it's just a lot of work. Of course "I properly diagnosed and treated acute hyperkalemia" doesn't look good on a t shirt....

Now, the patients like this one, the minutes away from dying without quick, correct care type cases, that's what fills my sails. I much prefer SAS medicals over codes.


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## StCEMT (Jan 4, 2017)

hometownmedic5 said:


> I truly don't get how anybody finds excitement in a cardiac arrest. For sure, you do a lot of skills in a short period of time. No doubt about that; but if you look beyond the chaos, that's all it is. A skills lab.
> 
> The overwhelming majority of the time, a patient in cardiac arrest is not long for this world. Whether they stay dead in the living room, die in the box or the ED, or the ICU a week later; chances are very close to absolute they are going to die. Once you realize that, most likely, you're just flogging a dead horse in case your patient is in the 2 or 3 percent that are going to make it, it's just a lot of work. Of course "I properly diagnosed and treated acute hyperkalemia" doesn't look good on a t shirt....
> 
> Now, the patients like this one, the minutes away from dying without quick, correct care type cases, that's what fills my sails. I much prefer SAS medicals over codes.


I think it can be if you know that this person has good circumstances. By stander cpr, fast response etc. There have been a lot of good stories in my area this past year now that all the department's are getting on the same page and it's been awesome to see. Otherwise though, I agree. Looks sexy, but it's very straightforward.


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## Summit (Jan 4, 2017)

Codes are about simple problem solving and good compressions with minimized interruptions.

Post code management is far more interesting... it is critical care. So is managing a critical hyperkalemic hypoxic patient with CHF and ESRD.

But it depends what you like... codes are a big emergency... critical care is optimized management of a combination of emergencies, some of which become big.


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## VentMonkey (Jan 4, 2017)

Summit said:


> Codes are about simple problem solving and good compressions with minimized interruptions.
> 
> Post code management is far more interesting... it is critical care. So is managing a critical hyperkalemic hypoxic patient with CHF and ESRD.
> 
> But it depends what you like... codes are a big emergency... critical care is optimized management of a combination of *actual life-threatening emergencies, not ones subjectively thought out by many patients seen in the emergency/ EMS setting*, some of which become big.


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## MonkeyArrow (Jan 4, 2017)

hometownmedic5 said:


> I truly don't get how anybody finds excitement in a cardiac arrest. For sure, you do a lot of skills in a short period of time. No doubt about that; but if you look beyond the chaos, that's all it is. A skills lab.
> 
> The overwhelming majority of the time, a patient in cardiac arrest is not long for this world. Whether they stay dead in the living room, die in the box or the ED, or the ICU a week later; chances are very close to absolute they are going to die. Once you realize that, most likely, you're just flogging a dead horse in case your patient is in the 2 or 3 percent that are going to make it, it's just a lot of work. Of course "I properly diagnosed and treated acute hyperkalemia" doesn't look good on a t shirt....
> 
> Now, the patients like this one, the minutes away from dying without quick, correct care type cases, that's what fills my sails. I much prefer SAS medicals over codes.


I wholly disagree, especially if you look at the literature that has been emerging in recent years in cardiac arrest resuscitation advances. Plus, trying to coordinate a well-run code is one of the hardest trials of leadership as a paramedic, for a well run code that is.


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## Akulahawk (Jan 4, 2017)

Summit said:


> Codes are about simple problem solving and good compressions with minimized interruptions.
> 
> Post code management is far more interesting... it is critical care. So is managing a *critical hyperkalemic hypoxic patient with CHF and ESRD.*
> 
> But it depends what you like... codes are a big emergency... critical care is optimized management of a combination of emergencies, some of which become big.


It seems like I've had a few of those in my ED... and we _always_ ship those out. Patients like that are pretty much beyond what our little (and I mean _little_) hospital can deal with, partly because we don't have dialysis capability that can get there fast enough. Most of the hospital EDs near my house are bigger than the entire hospital (ED included) that I work at. 

Oh and I'm so _not_ a fan of Kayexalate or Lactulose... Don't know if we have enough wet wipes for that but our docs order it anyway.


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## VentMonkey (Jan 4, 2017)

hometownmedic5 said:


> Of course "I properly diagnosed and treated acute hyperkalemia" doesn't look good on a t shirt....


Psssh, says you. I so want that on a t-shirt! How else would they know about my awesomeness??


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## StCEMT (Jan 4, 2017)

VentMonkey said:


> Psssh, says you. I so want that on a t-shirt! How else would they know about my awesomeness??


You narcaned their honors student?


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## NomadicMedic (Jan 4, 2017)

That's it. I'm making them.


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## VentMonkey (Jan 4, 2017)

DEmedic said:


> That's it. I'm making them.
> 
> View attachment 3366


Lol, that's absurdly hilarious.


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## hometownmedic5 (Jan 4, 2017)

MonkeyArrow said:


> I wholly disagree, especially if you look at the literature that has been emerging in recent years in cardiac arrest resuscitation advances. Plus, trying to coordinate a well-run code is one of the hardest trials of leadership as a paramedic, for a well run code that is.



The emerging data is hopefull true enough, but I don't feel it's representative and won't be for some time.

What is improving code stats? Lucas and CCR, right? While it won't be hard to get the majority of systems to move away from the old version of acls to a newer standard, there is never going to be a Lucas on every front piece in the country. It just isn't going to happen. I can very much see a gradual, perhaps begrudging move away from the "tube em and take em to the hospital" code management style of the past to a more modern look at it, but its going to be a long time before that's the actual standard, and a standard that is actually utilized.

Stay and play codes still aren't really a thing in most of my state. There is still this great rush to get them to the hospital to be pronounced. When we can get past that, we can start to see some of these improving outcomes you refer to. We still wont get the thumpers, but its a start.


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## VentMonkey (Jan 4, 2017)

hometownmedic5 said:


> Stay and play codes still aren't really a thing in most of my state.


Our county medical director just approved a 30 minute rule where if no changes prior to, or at the 30 minute mark, we're done.

I think at least where I am, it may take a bit of reeducation, and cultural shifting on the behalf of some of our fire first responders, but only time will tell how well it plays out. 

I like the idea, personally, and was taught to work them up before transporting. I have had "talks" with fire captains before in regards to this. I think another issue is some of the newer, less "command-presence inclined" providers in my area allowing fire to dictate the pace of the code.


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## NomadicMedic (Jan 4, 2017)

We don't stay and play on codes here, either. Someday. I keep pushing for it.


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## StCEMT (Jan 4, 2017)

VentMonkey said:


> I like the idea, personally, and was taught to work them up before transporting. I have had "talks" with fire captains before in regards to this. I think another issue is some of the newer, less "command-presence inclined" providers in my area allowing fire to dictate the pace of the code.


That's one thing I am thankful for. I have the potential to work with a lot of different fire departments, but we have all gotten on the same sheet as far as how we run these. I haven't personally had to work with them yet, but its nice knowing we all know where our role is when the time comes.


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## VentMonkey (Jan 4, 2017)

StCEMT said:


> That's one thing I am thankful for. I have the potential to work with a lot of different fire departments, but we have all gotten on the same sheet as far as how we run these. I haven't personally had to work with them yet, but its nice knowing we all know where our role is when the time comes.


No doubt. Don't get me wrong, our relationships with these departments overall are great, but it's walking that fine line of doing what's in your protocols, best for the patient, and stroking some of their egos. 

Luckily for guys like me, the game gets easier to play, especially because I have zero qualms about diplomatically explaining to whoever were to ask me why I did, or didn't do something like "Joe the last medic" did or didn't do. I carry this with me regardless of the system, or agency.


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## StCEMT (Jan 4, 2017)

VentMonkey said:


> No doubt. Don't get me wrong, our relationships with these departments overall are great, but it's walking that fine line of doing what's in your protocols, best for the patient, and stroking some of their egos.
> 
> Luckily for guys like me, the game gets easier to play, especially because I have zero qualms about diplomatically explaining to whoever were to ask me why I did, or didn't do something like "Joe the last medic" did or didn't do. I carry this with me regardless of the system, or agency.


Yea, there have been a few times those lines get all wobbly. I'm just thankful that an arrest is less likely to be one of those times. Now if only they don't turn another 911 into a transfer to a nursing home again.....*******....

Diplomacy is generally best.


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## Summit (Jan 4, 2017)

VentMonkey said:


> *actual life-threatening emergencies, not ones subjectively thought out by many patients seen in the emergency/ EMS setting*



I made this matrix a while back...


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## VentMonkey (Jan 4, 2017)

Summit said:


> I made this matrix a while back...


I think you need to get together with @DEmedic and see about a shirt conversion.


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## Kevinf (Jan 5, 2017)

That EKG _is_ worrying.


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## Carlos Danger (Jan 5, 2017)

NPO said:


> Thank you. What are you considering Epi as treatment for?
> 
> Sent from my SM-G935T using Tapatalk



To shift some K back into the cells as a temporizing measure. Same mechanism as albuterol. Just throwing out ideas for things you could consider if you don't have venous access.


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## NPO (Jan 5, 2017)

Remi said:


> To shift some K back into the cells as a temporizing measure. Same mechanism as albuterol. Just throwing out ideas for things you could consider if you don't have venous access.


Ah okay. I've never heard it used for that.

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## StCEMT (Jan 5, 2017)

Remi said:


> To shift some K back into the cells as a temporizing measure. Same mechanism as albuterol. Just throwing out ideas for things you could consider if you don't have venous access.


Standard anaphylaxis dose or?


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## E tank (Jan 5, 2017)

[QUOTE="zzyzx, post: 632599, member: 5004"

Bicarb is an old-school treatment that is no longer the standard of care for hyperkalemia...[/QUOTE]

Don't know why, it works. Perfusionists  use it all of the time to drop the K+ coming off the bypass pump after cardiac surgery. Some patients can have potassium above 7 right before coming off of bypass and bicarb is indispensable for separation in those situations (along with Ca++ and insulin).


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## MackTheKnife (Jan 8, 2017)

NPO said:


> I attempted a single IV en route, but he had no access. I looked for an EJ, but I couldn't lay him down due to his reapritory status, and he had a large neck, and I couldn't find anything.
> 
> I agree, an IO was 100% appropriate, and I'm kicking myself for not doing it. It simply slipped my mind until too late into transport and we were already pulling up to the ER. In retrospect I should have moved straight to IO. His legs were also quite large, but I think I would've gotten it.
> 
> ...


No worries, just curious. 

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## CWATT (Jan 8, 2017)

Not sure how to delete posts.  (Sorry)


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## Eden (Jan 14, 2017)

Awesome case, i really like these cases, true emergency medicine.
Yea i guess you could throw an albuterol/ salbutamol neb but like others have said and from what i was taught, this is not whats gonna save that patient. 
The monitor strip, classic Hyperk- extremely wide QRS too slow to be vtach.


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## Nova1300 (Jan 16, 2017)

Just wanted to make a quick couple points...



MackTheKnife said:


> Insulin and Bicarb works effectively, but you don't carry insulin, do you?



Absolutely.  Insulin, usually given with dextrose, does cause intracellular shift of potassium.  And in a pinch, both are generally readily available in most patient care areas.  

Practically, however, I have found insulin:d50 therapy to be very unpredictable, both in its efficacy and the duration of the effect.  This seems to hold especially true in acidotic patients, who oftentimes laugh at insulin.  

That being said, I give it anyway.  And most of the ER docs do as well, I have found.  

Just to put a little perspective on this entire conversation, you guys bring us incredibly hyperkalemic dialysis patients all the time.  You just aren't around when the labs result.  That patient that missed a dialysis run or two, it's nothing for his K to be 7+.  The septic ESRD patient, also frequently 7+. As these patients go through years of potassium buildup and washout on dialysis, they adapt.  They tolerate higher potassiums in stride. We treat them anyway, but truth be told most would likely be fine until dialsysis can get started. 

 Honestly, what most hyperkalemic emergencies really need is fluids.  In my experience, volume expansion has been far and away the most effective method of quickly lowering plasma potassium concentration.  Recall that the potassium "level" is actually a measure of concentration, dissolved in plasma and measured in meq/L.  Humans have 40ml of plasma per kg of body weight. So in a 75 kg patient, about 3L of total plasma volume.  Mathematically, you can imagine how effective adding a liter or two to that would be in decreasing the plasma concentration.  

Fluids open, gram or two of calcium.  Bicarb if they have a metabolic acidosis.  Gentle hyperventilation if they don't.  Loop diuretics if the kidneys work.  Dialysis or CRRT if they don't.  

The insulin-dextrose is usually an afterthought for me.  Laxatives are only for revenge. Albuterol, sure why not.  But they aren't terribly effective, honestly.  

You have the best treatment readily available for $0.19/L.


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## NomadicMedic (Jan 16, 2017)

Nova1300 said:


> Just wanted to make a quick couple points...
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 I always enjoy when you weigh in Doc.


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## E tank (Jan 16, 2017)

Nova1300 said:


> Just wanted to make a quick couple points...
> 
> 
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I think you nailed it when you referenced the acidemic patient not responding to the insulin/dextrose cocktail. They don't respond to much of anything in the way of ino/pressor support either until that is fixed to one degree or another. In the highly artificial world of the OR, insulin/dextrose works very effectively and predictably, but that is when there is no acidemia, and the patient is normothermic and euvolemic. Even adding bicarb to someone that is not acidemic works pretty well with hyperkalemia when they are "perfectly" tuned. Not reality in emergency/CC, I know. 

But I wonder how volume overload changes your strategy in these patients that have missed a couple of days of dialysis?


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## VentMonkey (Jan 16, 2017)

E tank said:


> *Not reality in emergency/CC*, I know. But I wonder how volume overload changes your strategy in these patients that have missed a couple of days of dialysis?


In the emergent prehospital setting, not a whole lot one can do. 9 times out of 10 these patients present as the classic "flash pulmonary edema" with chief complaints of chest discomfort, and/ or dyspnea.

A well versed prehospital clinician should be able to put the pieces together for the receiving ED staff in order to hopefully push the patient towards the emergency dialysis route. Aside from the likelihood of th said patient getting CPAP in the field for flash edema, performing 12 leads, perhaps placing the patient on pads, and/ or monitoring for acute and lethal arrhythmias (i.e., sine waves) there isn't much else that would change their outcome in the field. 

Sure, the aforementioned cocktail everyone has eluded to will buy the time, but that's all it will do. For me less is more in an urban setting with reasonably short transport times. Perhaps and order for CaCl- PRN from the base in line with the "hey, 'X' patient needs emergency dialysis" in the face of extended transport times.

As far as the CCT setting, more often than not the sending is way ahead of the curve regarding the cocktail, but if not, I doubt it would be hard to argue against any standing orders/ consults with the sending, receiving, or both physicians. In the event that the patient required emergency intubation en route to the receiving facility, I would be more concerned with knowing the patients most recent lab work, as well as medical history and co-morbidities to properly reflect their ventilator settings.

This is alljus my spin on an out-of-hospital management style. Merely one way to skin the proverbial cat...


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## StCEMT (Jan 16, 2017)

What are y'all a thoughts on furosemide in these folks? I have it available, but I have no first hand experience with it. Also, in the event of pulmonary edema, would you still make an effort to give fluids after trying to help the edema? Or just let it be and the hospital can deal with it (time allowing).


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## VentMonkey (Jan 16, 2017)

StCEMT said:


> What are y'all a thoughts on furosemide in these folks? I have it available, but I have no first hand experience with it.


Lasix has fallen out of favor in the prehospital setting given is likelihood to increase ICU stays. Most of these patients are RF/ ESRD patients, and oftentimes are on more Lasix than I could ever double up on.

Nowadays when I think Lasix, it's more along the lines of a DI, or SIAD patient. Neither of which, I would be treating aside from supportive care in the field.


StCEMT said:


> Also, in the event of pulmonary edema, would you still make an effort to give fluids after trying to help the edema? Or just let it be and the hospital can deal with it (time allowing).


St, this is where the term "judicious fluid bolus" has a definite place. Frequent reassessments for worsening fluid shifts, third spacing, JVD, adventitious breath sounds, etc. are--as you're aware--crucial.

Walking that fine line of a "PAP-able" patient as well as one who needs fluid isn't worth withholding volume resuscitation if they need it, again, so long as it's prudently judicious.


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## NPO (Jan 21, 2017)

Nova1300 said:


> Just wanted to make a quick couple points...
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Thank you for your insightful comments!

Sent from my SM-G935T using Tapatalk


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