Board Review

Bored Review: 2/3/2015-EKG Changes that make you go hmmm.

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A 54-year-old female with diabetes, hypertension, end-stage renal disease on dialysis presents to the ED after “Snowmageddon” with a complaint of generalized weakness. She answers questions, but seems slightly confused. While awaiting for the initial vital signs, you feel her pulse and find that it is approximately 45. You place an IV while your colleague is putting the patient on the monitor. The PCA then hands you this EKG:sinusoidal ekg

 

Your first response is:

a) ask to see an old EKG

b) soil yourself

c) call the renal fellow to arrange for dialysis

d) administer 1 gram of calcium gluconate IV push

answer
OY VAY! This EKG is pathognomonic for hyperkalemia. Answer D is correct. Please administer calcium immediately. When a patient has hyperkalemia with EKG changes, there are several critical interventions that can save this person’s life. The goal is to decrease the potassium.  The next rhythm after this sinusoidal, wide-completx is ventricular fibrillation (that is resistant to defibrillation). There are several tactics employed to lower the serum potassium.

1) stabilize the cardiac cell membranes

2) shift potassium into cells

3) excrete potassium from the body

Below is a chart demonstrating the onset and duration of the medications used for the above strategy. Just don’t give sodium polystyrene. It causes more harm than benefit and takes too long to work.

Ultimately, the best way for our above patient to excrete potassium is by hemodialysis- AFTER THEY HAVE BEEN STABILIZED!hyperkalemia treatment

Rosen’s Emergency Medicine, 7th Edition.

By: Andy Grock and Sally Bogoch

 

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

1 comment for “Bored Review: 2/3/2015-EKG Changes that make you go hmmm.”

  1. Ian deSouza
    February 3, 2015 at 11:29 am

    Some additional, recent references regarding the treatment of hyperK:

    Mahoney BA, Smith WAD, Lo D, Tsoi K, Tonelli M, Clase C. Emergency interventions for hyperkalaemia. Cochrane
    Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003235. DOI: 10.1002/14651858.CD003235.pub2.

    Kovesdy, C. P. Nat. Rev. Nephrol. 10, 653–662 (2014); published online 16 September 2014; doi:10.1038/nrneph.2014.168

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