1. Shawn Dowling PGY-2 ECG Rounds ©Aric Storck

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

5.  Pt got ‘lytics  K+ was 8.9, Cr was 252  ECG did not change w/lytics, but with insulin/bicarb…

7. Case #2  87F  Feeling weak and dizzy  PMHx – heart failure, prior MI  Meds - on some heart meds – you know the little white ones…  ECG…

8. What do you think? How do you want to treat this patient?

9. 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?

10. Case #3  79M  2 hrs of RSCP (good story for ischemia)  Cardiac RF: all of ‘em  ECG…

12. What does hyperacute ischemic T waves have to do w/high K?

13. Summary  ECG findings ECG findings  Peaked T-waves (>5mm)  QT shortening  ST elevation  Increased PR/loss of P wave  Widening/Slurring QRS  Sine wave appearance Sine wave appearance  2 nd /3 rd degree block, VF, asystole Mild Moderate Severe

14.  Although the ECG findings may or may not correlate to lab findings, arrhythmias can occur @ any level of hyperkalemia

15. 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 VentolinNebs 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) Lasix10-80mg IVO: 1 hr D: 2-4 hrs Dialysis1 nephrology residentE: 1.2-1.5 mEq/hr KayexalatePt nice=PO 20gm Pt nasty=PR 50gm PO onset 1-2hrs PR onset 30 mins DrugDosageOnset/Duration Membrane Stabilizer* Shift* Excretion* *Tx w/ at least modality From each

16. Case #  46M.  C/O - Feeling unwell, muscle cramping and intermittent parasthesias  Admits to laxative abuse  VSS  ECG…

19. ECG findings  small or absent T waves  prominent U waves  ST segment depression  QT prolongation/Pseudo  VF/Torsades

20. Tx*  Mild (3-3.4mEq)  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

21.  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 1 st 24 hrs

22.  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

23. References  Rosen’s  eMedicine.com