Hyperkalemia Call Review

[NPO]

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]

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.

 

[NPO]

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]

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.

 

[PotatoMedic]

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.

 

[VentMonkey]

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.

 

[NPO]

Oh, and he had a cardiac EF of 10% not that it's relevant, but just more to the history. [emoji54]

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[StCEMT]

How was this dude feeling with a bgl of 30?

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?

 

[NPO]

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]

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.

 

[StCEMT]

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?

 

[VentMonkey]

@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.

 

[StCEMT]

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.

 

[VentMonkey]

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.

 

[Nova1300]

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.

 

[NPO]

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]

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.

 

[NPO]

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]

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.

 

[VentMonkey]

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.