NomadicMedic
I know a guy who knows a guy.
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That's it. I'm making them.
Hyperkalemia Call Review
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VentMonkey
Family Guy
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Lol, that's absurdly hilarious.
hometownmedic5
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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.
VentMonkey
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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.
NomadicMedic
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We don't stay and play on codes here, either. Someday. I keep pushing for it.
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.
VentMonkey
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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.....*******....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
Diplomacy is generally best.
Summit
Critical Crazy
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VentMonkey
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I think you need to get together with @DEmedic and see about a shirt conversion.I made this matrix a while back...
Kevinf
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That EKG is worrying.
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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.
OP
OP
NPO
Forum Deputy Chief
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Standard anaphylaxis dose or?
E tank
Caution: Paralyzing Agent
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[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).
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).
MackTheKnife
BSN, RN-BC, EMT-P, TCRN, CEN
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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.
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.
Just wanted to make a quick couple points...
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.
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.
NomadicMedic
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