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Shawn Dowling
PGY-2
ECG Rounds ©Aric Storck
Case #1
39M DM1 (poorly controlled), HTN, EtOH abuse,
recurrent pancreatitis Presents w/++NV, developed epigastric/CP O/E – HR 130, BP 70/30, Fluid: Dry, anuric Cardiac exam - Normal
Pt got ‘lyticsK+ was 8.9, Cr was 252ECG did not change w/lytics, but with insulin/bicarb…
Case #2
87F Feeling weak and dizzy PMHx – heart failure, prior MI Meds - on some heart meds – you know the little
white ones… ECG…
What do you think? How do you want to treat this patient?
A few hours later the clinical clerk shows you her repeat ECG, and says “cool I’ve never seen an ECG like this…”
Do you want to change any of your meds for treating her high K?
Case #3
79M 2 hrs of RSCP (good story for ischemia) Cardiac RF: all of ‘em ECG…
What does hyperacute ischemic T waves have to do w/high K?
Summary ECG findings
Peaked T-waves (>5mm)QT shorteningST elevation Increased PR/loss of P waveWidening/Slurring QRSSine wave appearance2nd/3rd degree block, VF, asystole
Mild
Moderate
Severe
Although the ECG findings may or may not correlate to lab findings, arrhythmias can occur @ any level of hyperkalemia
Ca Cl or Gluconate
10mL of 10% over
10 mins (Cl = 360mg, Gl=93mg)
O:0-5 mins D:1 hr
Insulin & (Glucose)
10-20u bolus (if c/s <14mmol give glucose)
O: 15 mins D: 4-6 hrs
Effect – 0.6-1.0
Ventolin Nebs 5-20 mg
IV 0.5mg
O: 15 mins D: 2-3 hrs
E: N 0.5-0.9/IV .8-1.5
Na Bicarbonate
One Amp (44mEq) O: 15 mins D: 2 hrs
4 studies – 0 but small studies (5-10 pts)
Lasix 10-80mg IV O: 1 hr D: 2-4 hrs
Dialysis 1 nephrology resident E: 1.2-1.5 mEq/hr
Kayexalate Pt nice=PO 20gm
Pt nasty=PR 50gm
PO onset 1-2hrs
PR onset 30 mins
Drug Dosage Onset/Duration
MembraneStabilizer*
Shift*
Excretion*
*Tx w/ at least modality From each
Case #
46M. C/O - Feeling unwell, muscle cramping and
intermittent parasthesias Admits to laxative abuse VSS ECG…
ECG findings
small or absent T waves prominent U waves ST segment depression QT prolongation/Pseudo VF/Torsades
Tx* Mild (3-3.4mEq)
PO replacement Moderate (2.5-3.0 mEq)
Minimal Sx and N ECG – PO replacementSignificant Sx and/or ECG changes – IV
Severe (<2.5 mEq) IV KCl
*Check Magnesium – replace if low or borderline
K deficit = desired K – meas K x .25 x wgt (kg)Only an approximation since most K is intracellularWant to replace 75% of K w/i 1st 24 hrs
Oral K-Dur (20mmol/tab) KCl elixir(20mmol/15ml) K-Phos(4.4mmol/ml)
useful if hypophosphatemic K-Citrate (0.9mmol/ml)
useful in RTA
IV KCl (10/20/40mmol/100cc) 10-20mEq/h >20mEq/h requires central
line and cardiac monitor
S/E’s transient hyperkalemia burning at IV site
Thanks for the slide Aric
References
Rosen’s eMedicine.com