ECG Rounds ©Aric Storck Shawn Dowling PGY-2

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 ‘lytics K+ was 8.9, Cr was 252 ECG 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 shortening ST elevation Increased PR/loss of P wave Widening/Slurring QRS Sine wave appearance 2nd/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

Drug Dosage Onset/Duration Ca Cl or Gluconate 10mL of 10% over 10 mins (Cl = 360mg, Gl=93mg) O:0-5 mins D:1 hr Glucose & (Insulin) 10-20u bolus (if c/s <14mmol) 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 Membrane Stabilizer* 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) Moderate (2.5-3.0 mEq) Severe (<2.5 mEq) PO replacement Moderate (2.5-3.0 mEq) Minimal Sx and N ECG – PO replacement Significant 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 intracellular Want to replace 75% of K w/i 1st 24 hrs

Oral IV S/E’s K-Dur (20mmol/tab) KCl (10/20/40mmol/100cc) 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