Case 8

78 year old female

Brought in by SCDF ambulance. Acutely unwell.
BP 85/50, Temp 37.8. Drowsy and unresponsive.
No family members around to give more history.

What is the diagnosis?
Which drug would you give first in her management?

Answer : Hyperkalemia

On first look, the ECG looks bizarre and not like something which we can fit a pattern to. This in itself should already remind you to think of hyperkalemia. On closer inspection we can see that the QRS complexes are widened and there is also suggestion of tall T waves.

Management

• Immediate management in P1 area. Full monitoring.
• Supplemental oxygen
• IV access; take blood form FBC/ UE/ ABG/ cardiac enzymes & Troponin/ blood cultures; consider IV fluids but need to exclude fluid overload first
• Drugs

1. IV Calcium gluconate/ chloride (10 mls stat) - first drug to be given in treatment of hyperkalemia; to stabilise the myocardium
2. IV Insulin 10 units with IV Dextrose 50% 40 mls - shifts ECF potassium into ICF
3. IV Sodium Bicarbonate (1 meq/kg BW ) IV bolus over 5 mins - also to shift ECF potassium into ICF. Limited use if patient is non-acidotic, and carries risk of fluid overload/ cerebral oedema.

Other drugs which can be considered include Salbutamol nebulisation (be careful in patients with IHD because of resultant tachycardia), as well as Resornium (K-binding resin) but it's not much use in A&E because of relatively longer onset of action (about 1-2 hrs).

This lady has a history of chronic renal impairment on dialysis. Her acute presentation is probably exacerbated by a concomitant infection (chest/ urine).

Remember :

• Consider non-cardiac pathologies when intepreting ECG
• When confronted with bizarre-looking ECG, consider severe hyperkalemia