Emergency Medicine Forum

As you begin your shift, a guard with a prisoner, watch as you go by.  The guard asks impatiently:  ‘Hey Doc, we been here for two hours, can you check this guy out and get him shipped back to jail? I’m off shift in 30 minutes and I need a replacement if we have to wait much longer”.

You grab his chart (behind the next in queue) and get more history.

Patient is a 32 y/o patient, with history of chronic renal failure, dialysis Monday, Wednesday, and Friday (today is Tuesday).  He also has a history of Hypertension (causing the renal failure).  He was supposed to help in the kitchen today, but complained he was too weak to work.  The nurse looked in on him and tried to get him to work, but he wouldn’t walk very far before sitting on the ground complaining he was too weak to walk.  The nurse then sent him to the hospital.

Patient states weakness is all over, legs slightly more than arms.  This has never happened before, and he has no idea what it is from. His dialysis yesterday was uneventful, and the prison gives him all his medications. 

ROS:  No fevers, no cough, no SOB, no nausea, no vomiting, no diarrhea, no rashes.  No recent travel.
PMH:  HTN, CRF/dialysis
SH:  Smoker (when he has cigarettes), past drug abuser
FH:  Unremarkable
PE:  160/88, HR = 92, RR=20, afebrile.  Sat (RA)=96
HEENT: Unremarkable
Heart:  RRR, no murmurs, no gallop
Lungs:  Clear bilaterally, no rales
Abd soft, muscular, non-tender
Ext:  No rashes, nl tone, strength 4/5 all extremities.  Reflex’s 2+ and normal.
Gait:  Patient would take a few steps then complain and grab the gurney to lie down again.

1. What is the first concern you need to have, and what do you need to do?

Any dialysis patient with complaints that might be related to hyperkalemia, need an immediate EKG, and IV access to treat the hyperkalemia if present.  One reference noted 67% mortality if not treated immediately.  Hyperkalemia is divided into mild:  (5.5-6.0), Moderate (6.1-7.0) and Severe (>7.0) mEq/L.  Frequent complaints from patients suffering hyperkalemia include:  Generalized fatigue, weakness, paresthesia, paralysis, palpitations. Just based on his complaint and history of dialysis, hyperkalemia has to be assumed until proven otherwise.

2. Should you move him from the hallway?  Or can you start the work up there?

Any patient with possible hyperkalemia should be placed on continuous monitoring.  It is not unusual to watch the progression from peaked T waves, to a bundle-branch block, to a wide complex rhythm, to a sine wave.  Just based on his complaint and history of dialysis, hyperkalemia should be a very real concern.

3. Is his condition life threatening?

One reference noted 67% mortality if not treated immediately.  (Nice review at: http://www.emedicine.com/EMERG/topic261.htm)

4. If your suspicions are confirmed, how would you treat?

If EKG changes present, then treatment must be initiated immediately.

1. Calcium is the first agent as it is cardio protective, and antagonizes the kyperkalemia.  It will protect the heart for only about one hour, so is never used alone.  Do not use if the patient may be digitalis toxic.

2. Glucose and Insulin:  1 Amp D=50 and 5-10 units of insulin. This causes a shift in K, so will only temporize.  Definitive removal of K still needs to occur.

3. Sodium Polystyrene sulfonate (Kayexalate).  This actually removes potassium from the body.  It can be given orally or as an enema. (which nurses hate!—but works)

4. Albuterol by inhalation—will lower K by 0.5-1.5 mEq/L.  Lasts 2-3 hours. 

5. Bicarbonate:  Somewhat controversial, but some still use.  It raises the blood pH and causes shifts H+ for K+.  Only lasts 15-30 minutes.

6. Furosemide (Lasix) (if the patient makes urine), can increase excretion of K+.

7. Dialysis:  definitive treatment—removes K= quickly and consistently.

(Nice table in Tintinalli describing these meds.)

5. At what level should you treat?

All experts suggest treatment if EKG changes are present, and two textbooks suggest without EKG changes to treat at >6.5 mEq/L even if no EKG changes present.  (1,2).  Another reference that quotes the 2005 ACLS guidelines suggests treatment with everything except calcium for levels >6.0mEq/L if no EKG changes. (http://www.kidneynotes.com/2006/01/treating-hyperkalemia-high-blood.html).  Tintinalli (Fifth edition) suggests using calcium in addition to the other medications at level of 7.5mEq/L even if no EKG changes present.

This patient was treated based on EKG abnormalities, level came back at 7.5 mEq/L and he was emergently dialyzed.  As he was in prison, on a low potassium diet, some thought he was intentionally ingesting potassium (not sure from what source—maybe a friend smuggling it in?) to get out of jail for a time.

About one month later, when coming on for a shift, the same patient saw me and yelled:  “Hey doc, you remember me?  You gotta come over and help me, I’m sick like I was before….”  The guard again looked skeptical. I immediately put him on the monitor (wide complex, no P waves) established an IV and started treatment for Hyperkalemia.  This time level was 8.2mEq/L.  Ultimately, the inpatient team investigated and found out that the jail had changed to a new salt substitute—yep, you guessed it…KCL (a common salt substitute!). 

1. Stein R, Marcus R.  A Practical guide to emergency medicine, Little Brown and Company, page 143-4

2. Hardwood-Nuss A, Luten R.  Handbook of Emergency Medicine. L. B. Lippincott, 1995, page 521.