Hypokalemia

[GMCmedic]

Dispatched to an urgent care for a female with abdominal pain. Upon arrival, find a 64 y/o female sitting on an exam table. She appears to be in pain.

LPN says patient hasn't felt right for a few weeks. Yesterday after mowing the grass she began having abdominal pain and diarrhea. Today she began vomiting.

Despite having the capabilities to do 12 leads, labs, and CT, the urgent care center has done nothing but give 8mg Zofran ODT which hasnt really helped.

Blood pressure was all over the place 170/90- 200/90 manual. Stuck a 22 gauge in her right forearm. Patient refused pain medication. 12 lead showed sinus with flattened T waves and U waves in V4-V6.

I later followed up and patients Potassium was 2.8.


My question, and I feel like I should know this but Im drawing a blank.

We have a suspicion for Hypokalemia, do we want to give fluids to this patient or no? In general, when we have suspected or confirmed hypokalemia in any patient, are we going to be aggressive with fluids, or start replacing the potassium?

Obviously this patient does not need aggressive prehospital fluids, I believe I only gave her about 60ml.

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[DesertMedic66]

I have never heard or seen any information talking about fluids for hypokalemic patients in the EMS setting.

I did a quick reference in my medic texts and CCT texts and there was no mentions of fluids for the patient.

 

[GMCmedic]

I have never heard or seen any information talking about fluids for hypokalemic patients in the EMS setting.

I did a quick reference in my medic texts and CCT texts and there was no mentions of fluids for the patient.

Im really not seeing much either. Just thinking maybe we should address the potassium before we make that patient start peeing, but maybe im over thinking it.

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[E tank]

You might just end up diluting the extracellular K the patient does have by giving fluid she doesn't need.

 

[Summit]

I think you are asking what do you do if they are both hypovolemic and hypokalemic?

In the hospital we have lot's of choices for maintaining or slowly raising K+ while giving volume: oral potassium, NS with 10mEq/L K+, NS with 20mEq/L K+, Plasmalyte (5mEq), LR (4mEq/L), D5 0.5NS with 20mEQ/L of K, etc etc etc and we can add lidocaine to the drip (although this has questionable efficacy in treating the "MY VEINS ARE ON FIRE" side effect of peripheral IV K+ administration).

Generally we are only going to give 10mEq/hr peripherally so these are for maintenance or minor correction. If you have a profoundly hypokalemic patient throwing PVCs or other significant EKG changes you want to fix fast, you give concentrated IV like 10mEq in 100mL or 20mEq in 50mL, but you HAVE to have a central line. But usually you'd try oral K first. You might even do both at the same time. I've given 40mEQ of oral K+ while running 40mEq of K+ IV in an hour.

You can also use the concentrated CIV administered K+ if the patient is volume overloaded/sensitive are NPO or cannot handle oral K (comes in a giant pill or nasty tasting solution, both of which induce nausea in many patients).

Rule of thumb is 10mEq K+ IV will get you a serum K+ increase of about 0.1mEQ, while you need 20mEq oral for the same effect.

It is rarely emergent because the cause of the hypokalemia is rarely acute. Only when you have hyperacute water intoxication (usually a psych issue) are you fighting a clock. Usually who have a chronic issue that has gone unaddressed (eg on lasix but stopped taking K supplements or their HCTZ).

In the field, what do you have to treat hypokalemia? LR? You slam 2L of LR and you are going to increase serum K+ by less than 0.1mEq/L. You won't fix the K, but it is better than dropping it by ~0.2 with 2L of NS if you suspect hypokalemia.

 

[VentMonkey]

How about I just lock off my line, monitor for acute changes within my scope, transport, and intervene as necessary?

 

[DesertMedic66]

How about I just lock off my line, monitor for acute changes within my scope, transport, and intervene as necessary?

Well that’s just no fun at all

 

[GMCmedic]

How about I just lock off my line, monitor for acute changes within my scope, transport, and intervene as necessary?

Thats boring.

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[StCEMT]

How about I just lock off my line, monitor for acute changes within my scope, transport, and intervene as necessary?

 

[VentMonkey]

Thats boring.

Ok, but I'm still doing my job...proficiently.

 

[GMCmedic]

Ok, but I'm still doing my job...proficiently.

My interest is purely for learning the critical care side of it. Its not going to change anything for me at the moment cause I never actually know what the potassium level is till after the fact, I'm pretty sure with my transport times I would never give enough fluid for it to matter (which is probably why we teach fluids for everyone in EMS).


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[VentMonkey]

My interest is purely for learning the critical care side of it. Its not going to change anything for me at the moment cause I never actually know what the potassium level is till after the fact, I'm pretty sure with my transport times I would never give enough fluid for it to matter (which is probably why we teach fluids for everyone in EMS).

Sure, but even at the critical care (flight) paramedic level, an acutely hypokalemic patient would most likely present with symptoms fitting a different algorithm altogether, unless you're referring to the IFT arena.

Also, I can't recall the last time any advanced cert instructors of mine made acute hypokalemia something worth reviewing.

I'm not saying it's something that isn't a thing, or that we can't learn from or about. I am saying that the BCCTPC does not seem all that concerned with it, nor do many of the CCP courses or exams.

This is definitely something that the ICU nurses on here are certainly better equipped, and informed to educate about.

 

[medichopeful]

If you have a patient who is hypokalemic and needs fluids, the fluid of choice would be something containing potassium. Fluids without potassium could lead to a further decrease in potassium levels through dilution or other electrolyte shifts.

You also mentioned concerns over making the patient start voiding, which I give you credit for (thinking about the long-term picture, not just the "in-the-moment" picture). With that being said, you generally don't pee out potassium (with some exceptions such as lasix).

This patient doesn't really sound like they need any fluids at the moment (besides K+ replacement, which could be done through IV potassium at the hospital. I definitely wouldn't give this patient PO potassium due to the vomiting). For other patients with hypokalemia, I'd be really cautious about fluid resuscitating them unless you have potassium to give as well.

Also, any idea what this patient's BGL/FSBS was?

 

[GMCmedic]

IIRC her BGL was 140ish


She does not take lasix but she does take losartan HCTZ which im not as familiar with.

As you said though, im not really concerned with this patient, or really even a 911 setting. I would be more concerned in an IFT setting. We do transfers out of a CAH with less than stellar physicians. In fact most of the ED physicians are family practice trained. They do pretty well all things considered, but a few of them get distracted by one thing and miss another.

Also we no longer carry LR, its NS or nothing.
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[E tank]

Also we no longer carry LR, its NS or nothing.

 

[GMCmedic]

View attachment 3987

I just work here.

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[E tank]

I just work here.

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I know, I know....

 

[Nova1300]

I would not go overboard with fluids in this patient, but she certainly does need volume. For several reasons. And I think it's reasonable to give her a judicious fluid bolus in the field.

A couple of points- this patient is markedly hypertensive. That is a vascular response to her low plasma volume. It means her RAAS system is on full blast and her kidney perfusion is likely poor. You will benefit her kidneys and her hypertension by giving her some volume.

And yes, you will have a dilutional effect on the serum potassium. But with judicious fluids, that effect is likely clinically irrelevant. What you will achieve is to slow or stop the potassium loss.

When the kidneys sense that they ain't getting enough "preload" if you will , they will start to resorb sodium in the collecting system. Which makes sense, because water follows sodium back into the vasculature. Problem is, that ion pump that resorbs the sodium kicks a potassium out every time it does so. By giving a little volume, the kidney will not be as avid to resorb that sodium, thus slowing the loss of potassium.

Whew, I just had a bourbon. I hope that made sense.

 

[Nova1300]

Ok, I went to Wikipedia and I'm not quite right. It looks like it involves a pump that exchanges H+ and K+. But either way, you pee out K when you are alkalotic and volume depleted.

 

[E tank]

The fun about these anonymous on-line masturbatory threads is that they're anonymous and maturbatory .....Thus I now publicly and anonymously masturbate:

I think contributing to the blood pressure, in addition to her renin-angiotensin system is her pain. She has vasomotor tone in spades, which is notable because sympathetic tone in 64 year olds isn't usually very impressive. I'm not that impressed with a one day history of n/v/d. She could very easily be acidotic from what volume losses she's incurred, her hypokalemia notwithstanding.

In the end, some crystalloid on the way in will not hurt this lady at all, but getting her pain under control (pancreatitis?) is a priority. A better IV for a potassium bolus at the hospital and concomitant volume replacement would seem to be in her future.