ERDoc Posted December 17, 2007 Author Share Posted December 17, 2007 Coming in late on this one too....Wow, that is an ugly ECG. Wide complex, nasty T-waves...Like everyone else, my first thought is hyperkalemia. Does she normally have an irregular pulse? How does she describe the funny feeling in her chest? Is she still oriented? Since she's now feeling worse, let's lay her down, bump up the oxygen, and give more fluid challenges (paying close attention to lung sounds), and will seriously consider dopamine. Of course we are enroute to the ER, preferably a cardiac care center. Sodium bicarb sounds like a good idea too, but I would consult with a physician before I did that. Someone mentioned albuterol. I understand that this is a treatment for hyperkalemia and that it shifts K+ into the cells, however I'm not well educated on everything that's involved with that use. (Our transport times are usually 5-10 minutes, and we don't have any protocols for treating hyperkalemia except in a full arrest.) She is awake and talking, fully oriented. She does have a history of afib which is why she is on the Dig. Other than a funny feeling, sha cannot describe the sensation in her chest. You cannot contact a physician so you must make the decision to give or not give bicarb. Yes, albuterol does help to push the potassium back into the cells. Link to comment Share on other sites More sharing options...
ERDoc Posted December 17, 2007 Author Share Posted December 17, 2007 Good case! So, she is taking her standard K-dur supplement, however is taking less lasix recently. She is also on digoxin. So, the million dollar question; is she hyperkalemic secondary to acute dig toxicity, or is she hyperkalemic secondary to increased (relative) pottasium load? Or, is there another underlying pathology, that would be unlikely for us to flesh out in the field? Clearly her cardiogram is of concern, and her sx's are worsening as we speak. I'd likely discuss this case with med control, but I'll make a leap and assume the radio is dead, no batteries, doctor is in the head, etc.... Fluid challenge sounds like a plan, nebulized albuterol, and NaHCO3....I'm on the fence with Ca+ because of the distinct possibility this is secondary to her dig, If I were to give the calcium I would go with gluconate v.s. chloride, preferably after MD consult. You have obviously read my scenarios before. You contact medical control, but your doc is busy with a booty call in the call room. So, you have no MD to consult, do you or do you not give the Calcium? Link to comment Share on other sites More sharing options...
p3medic Posted December 18, 2007 Share Posted December 18, 2007 LOL! I would give the bicarb and albuterol, along with some fluid, and transport....if things get worse, (yes, I know, they will) yes, I'd give the calcium, very, very slow. There is a school of thought that hyperkalemia of this severity, i.e pending sine wave that tx with calcium is appropriate. There is also a long standing dogma that calcium can precipitate or exacerbate hyperkalemia with patients on digoxin. So, if the patient widens out more, become more symptomatic, I guess I'd give the calcium, short of that, no. Hows that for a cop out? Link to comment Share on other sites More sharing options...
ERDoc Posted December 18, 2007 Author Share Posted December 18, 2007 LOL! I would give the bicarb and albuterol, along with some fluid, and transport....if things get worse, (yes, I know, they will) yes, I'd give the calcium, very, very slow. There is a school of thought that hyperkalemia of this severity, i.e pending sine wave that tx with calcium is appropriate. There is also a long standing dogma that calcium can precipitate or exacerbate hyperkalemia with patients on digoxin. So, if the patient widens out more, become more symptomatic, I guess I'd give the calcium, short of that, no. Hows that for a cop out? I think I see a presidential nomination in your future p3. You give the bicarb and albuterol. As you guessed, she continued to get worse. You push the calcium VERY slowly. The pt suddenly becomes short of breath. You hear rales from top to bottom. She rapidly deteriorates and buys herself a tube. Shortly thereafter she codes. The ED works her but she is pronounced dead. WTF???? What happened here? Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 18, 2007 Share Posted December 18, 2007 Hot grandma here was having left ventricular failure, noted by the left BBB. The decrease in work load of the left ventricle caused her BP to get low. On top of that she was treated for a metabolic problem that she probably wasn't having. Her low BP to begin with, plus calcium (which will cause peripheral vasodilation) caused her BP to drop even more. With the lack of pumping action of the left ventricle the right ventricle was pumping blood to the lungs which caused the pulmonary edema. Had I been here to intervene earlier I'd have had a dopamine ready for if her perfusion is decreased, not given any calcium, and have given some ASA, and high flow O2, and rapid transport to a hospital. The nausea, dizziness, and what appears to be a resolving MI in the left ventricle is what I think her problem was. Not the a-fib or a metabolic problem. Also since My agency can afford field serum marker tests I would want to do one on her. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted December 18, 2007 Share Posted December 18, 2007 too bad you weren't here, you could have saved her. Smarty pants Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 18, 2007 Share Posted December 18, 2007 too bad you weren't here, you could have saved her. Smarty pants I had to put some pants on before I showed up onscene, the smarty pants were the only pair left ! Link to comment Share on other sites More sharing options...
ERDoc Posted December 18, 2007 Author Share Posted December 18, 2007 Mateo, as smart as you may be, I hate to tell you this, but you are wrong. This patient has hyperkalemia. This is from her still taking her old dose of KDur but taking less Lasix. The EKG changes are purely from the high postassium. She deteriorated rapidly after a VERY SLOW push of IV calcium. Why? Mateo, I agree that had she gotten the calcium rapidly it would have vsodilatory effects, but this is not the case here. This is a patient with EKG changes from hyperkalemia. This needs to be treated immediately. Standard therapy is IV insulin, glucose, bicarb, calcium and +/- albuterol as well as PO kayexalate. In most cases the calcium helps stabilize the cardiac membrane. What went wrong in this case? Link to comment Share on other sites More sharing options...
DwayneEMTP Posted December 18, 2007 Share Posted December 18, 2007 The calcium made her blood hypertonic. That, combined with the several fluid boluses caused the rales. The calcium and albuterol might have been ok without the extra fluid, but with it I think it was asking for trouble. Assuming we've quieted her hinky rhythm, we'll now need to try and un-drown her... That's my story and I'm sticking to it...(Unless it's wrong, then I'm going to blame someone) Edit: Ooops...I missed the part where she's dead. Link to comment Share on other sites More sharing options...
Mateo_1387 Posted December 18, 2007 Share Posted December 18, 2007 Stumped me...........I thought I knew this one, and did not do any research. Since I have done some research i have a new opinion of what the problem is. From what I can tell the digitalis is affecting her extracellular potassium levels by blocking the sodium potassium pump. I'm not sure how this affects the calcium in the cells and why extra calcium proves to be deadly. I'll definatly learn from this thread. Am I on the right track? Link to comment Share on other sites More sharing options...
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