Related Cases:
|Case #1 Potassium
|Case #2 Calcium
|Case #3 Calcium
|Case #4 Glucose
|Case #5 Shakes
|Case #6 Weakness
|Case #7 Headache
|Case #8 Weakness
|Case #9 Weakness
|Case #10 Weakness
|Case #11 Weak face
|Case #12 Weak eyes
|Case #13 Shakes
|Case #14 Confusion
|Case #15 Headache
|Case #16 Breathless
|Case #17 Unconscious
|Case #18 Breathless
|Case #19 Weakness
|Case #20 Breathless
A 67-year-old lady is admitted. She has heart failure and has recently been started on Spironolactone in addition to Bumetanide and Ramipril.
She feels nauseated and has malaise and has lost weight. She has felt so unwell that she has been in bed for the last few days and has hardy passed any urine. She has not been able to keep down any food or drink.
Obs show that her BP is 98/50 mmHg. O2 sats are 94%. Pulse is 65/min. Clinically she is dry. Her chest is clear and heart exam normal. Abdomen is soft and non tender. She has some mild pedal oedema.
These are her admission blood results
Chemistry Value Range Serum Sodium 128 137 - 144 mmol/L Serum Potassium 7.5 3.5 - 4.9 mmol/L Serum Chloride 100 95 - 107 mmol/L Serum Bicarbonate 17 20 - 28 mmol/L Anion Gap 11 12 - 16 mmol/L Serum Urea 21 2.5 - 7.5 mmol/L Serum Creatinine 312 60 - 110 micromol/L
1. What is the most concerning feature and how should you respond ?
- Start Telemetry and ensure defibrillator close by
- Get a 12 lead ECG done and at the same time
- Administer 10 mls of 10% IV Calcium Gluconate. Give slowly
What is the typical threshold for treating this
- Mild (K 5.5-5.9 mmol/L)
- Moderate (K 6.0-6.4 mmol/L)
- Severe (K >6.5 mmol/L) or if ECG changes or symptoms.
Start Emergency treatment when K >6.5 mmol/L or K >6.0 mmol/L and there are ECG changes. Give Calcium Gluconate and prepare Insulin and Dextrose
2. The ECG is shown below - please reveal. What are the classical ECG changes. She has now a Blood pressure of 90/60 and feels unwell.
ECG signs of Hyperkalaemia
- Peaked tented T waves
- Absent P waves
- Broad QRS
- Sine waves
- Bradycardia
- Agonal rhythm
- Cardiac arrest with VT/VF.
3. What might you wish to do
- If dry or euvolaemic consider IV fluids
- Give a further 10 mls of Calcium Gluconate again slow IV and ask the nurse to prepare
- 10 U of Short acting Insulin (Actrapid) with 100 ml of 25 % Dextrose or 50 ml of 50% dextrose
- Also consider nebulised salbutamol 10mg to 20mg, as tolerated. Give 10mg salbutamol if elderly, arrhythmias, ischaemic heart disease or tachycardia
4. After 30 mins the ECG changes revert. Repeat shows the level is 6.5 mmol/L what else might you consider
- Ensure that you stop Spironolactone. It may be reasonable to retart the ACEI after a few days if K remains normal with ongoing monitoring.
- Start Calcium Resonium 15 g 6 hrly to help remove potassium. Other similar agents are available now. This has little effect acutely and takes days to have an effect.
- Low potassium diet is wise. Ask for dietetic help if needed.
- Continue to monitor U&E for several days until safely down.
- The hope is that stopping spironolactone will help.
- Consider NaHCO3 if HCO3 < 15 mmol/L
5. If the patient was anuric or the K failed to respond to treatment what would you options be Question
6. The patient collapses and appears to be in cardiac arrest. CPR is started. What might you do
- Follow the usual ACLS algorithm for shockable and non-shockable rhythms
- If suspicious one would conform hyperkalaemia using a blood gas analyser if available but here we have a high suspicion here. An ABG is sent and the K is 8.5
- Protect the heart: give further 10 mL calcium chloride 10% IV by rapid bolus injection. Consider repeating dose if cardiac arrest is refractory or prolonged.
- Consider further 10 units soluble insulin and 25 g glucose IV by rapid injection. Monitor blood glucose. Administer 10% glucose infusion guided by blood glucose to avoid hypoglycaemia.
- Shift potassium into cells: Give 50 mmol sodium bicarbonate (50 mL 8.4% solution) IV by rapid injection.
- Remove potassium from the body: Consider dialysis for refractory hyperkalaemic cardiac arrest.
- Consider the use of a mechanical chest compression device if prolonged CPR is needed.
- Consider ECLS or ECPR for patients who are peri-arrest or in cardiac arrest as rescue therapy in those settings where it is feasible.