Hyperkalemia Call Review

[MackTheKnife]

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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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.

 

[MackTheKnife]

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

 

[Brandon O]

@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.

 

[MackTheKnife]

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.

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

 

[VentMonkey]

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.

 

[NPO]

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]

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.

 

[Carlos Danger]

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.

 

[VentMonkey]

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.

 

[NPO]

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]

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.

 

[Summit]

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.

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.

 

[hometownmedic5]

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.

 

[StCEMT]

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.

 

[Summit]

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.

 

[VentMonkey]

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.

 

[MonkeyArrow]

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.

 

[Akulahawk]

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.

 

[VentMonkey]

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??

 

[StCEMT]

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

You narcaned their honors student?