Oh no, not another one

[ERDoc]

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?

You are close. Look up some more on the mechanism of action for Dig and you might find the answer.

[flight-lp]

What went wrong in this case?

Pre-exisiting Hypercalcemia?????

Personally, I never give Ca+ to a pt. unless I can establish a baseline level or they are in arrest. Bicarb, great, Albuterol, sure, D50 and Insulin, wonderful. But just having peaked T's, no chance I would risk the acute potential by giving Ca+.

I figure this is one of 4 causes.

1. Excessive load possibly from the K+ supplement. Perhaps rhabdo should be considered, look for trauma and don't keep the tourniquet on for too long when starting your line.

2. A redistribution issue. Is it the Dig, is she acidotic, is she lacking Insulin production?

3. An excretion issue. Acute renal failure??

4. A lab screw up! Oh wait, those never happen! Besides the EKG is a prime indicator so we can scratch this one.............

I would also inquire about recent surgeries, especially those requiring general anesthesia (i.e. paralytics).

Interesting that no one suggested Mg+ for the possible Digoxin issue. It would be a little safer in my mind compared to Ca+.

Interesting presentation Doc!

[p3medic]

We actually have a hyperkalemia protocol, and in the case of a patient on digoxin, a call to medical control is mandatory. We have the option of calcium gluconate or calcium chloride, at the MD's discression. The only time we would give calcium fast, i.e over less than 2 min would be in the setting of cardiac arrest, otherwise we administer it at 100mg/min. There has been a long standing debate over the use of calcium in the setting of hyperkalemia with patient known to be taking digoxin. There have also been a few studies involving animals (dogs, pigs, guinea pigs) that showed no increase in death when calcium administered to animals taking digoxin at toxic levels. With that being said, I know that digoxin causes an increase in intracellular ca+ and andministering ca+ could potenially interfere with the Na-K ATPase pump, causing an increase in extracellular potasium and essentially stoping the cells ability to depolarize. (bad) So, I would hope my medical director would be kind.

[Niftymedi911]

Forgive my newness to this item,

I'm not quiet undertstanding the whole set-up.... I mean I get the lack of intracellular potassium in the myocardium causes the failure due to the overabundance of intracelluar calcium and fluid in her system, but what I don't understand is the rest......... The 12 lead is ugly and I could of sworn the same with what Mateo had stated. I agree with the LBBB but I also see the tall T waves. Was the hyperkalemia causing the left bundle branch block?

[Mateo_1387]

You are close. Look up some more on the mechanism of action for Dig and you might find the answer.

I know this was last year, but I was looking through my old posts and came across this one. So I was thinking about what the answer would be and this is my newest conclusion.

The patient is hyperkalemic. She also takes Dig, so that is going to inhibit the sodium potassium pump. So we give Calcium to counteract the potassium, hopefully causing it to enter into the cell by the CaCl gradient.

So, so far we have increased potassium, and increased calcium, but we do not have increased sodium. So the sodium that enters the cell is not able to cause depolarization of the cell and the patient ends up ends up in cardiac arrest. I guess the way I am thinking of it is the calcium and potassium are kind of like a Sodium channel blocker, they do not allow the sodium to work.

I am really digging on this one. If this is not the answer, let me keep working on it, please.

Thanks

Matt

[ERDoc]

Wow, Mateo, thanks for bringing this one up. I guess I left you guys hanging, sorry about that. So, this patient has hyperkalemia from taking less lasix but still taking the same dose of KDur. She has EKG changes consistent with hyperkalemia so she needs to be treated as quickly as possible. Treatment would include albuterol, IV insulin, IV D50 and kayexalate. Normally you would also give calcium to stabilize the cardiac membrane, but this pt has an confounding issue. She is on Dig which increases intracellular calcium levels. Giving additional calcium will cause a stone heart leading to death. As someone said previously this is based on some older literature. Some small animal studies in more recent literature says it may be safe to give calcium, but who wants to end up as a case report. Although it is not available in the field, you can give digibind and hope for the best in cases of extremis.

[StrchrFetchr]

Jumping in late... If I hadn't just read the answer here, I was going to toss out the "Well, we did give a rather high amount of sodium" part, by giving Sodium Bicarb. Although I could only imagine [As I haven't experienced...yet] that Heart failure wouldn't be that rapid, it's still a possible sequelae down the road.

Good scenario, ERDoc, thanks!

~Stretch

[WendyT]

I'm curious, but do you medics carry salts on board, and what are it's uses?

One medic I met last week mentioned this to another medic, something about this 87 yr old woman they picked up, this medic steve said she was a complete mess and the word salt came into conversation. :roll:

Ok sodium bicarb, I just happened to see this after I posted this, he mentioned that.