Académique Documents
Professionnel Documents
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October 2009
InFocus
By James R. Roberts, MD
cases demonstrated a rather marked decrease in serum potassium levels following treatment. In one case the
potassium level went from 8.1 mEq/L
to 6.6 mEq/L following calcium, insulin,
bicarbonate, and Kayexalate therapy.
Additional cases demonstrated more
severe EKG findings that exemplified
the classic sine wave morphology. In all
cases, the clinicians appeared clairvoyant enough to institute empiric therapy
against hyperkalemia based on EKG
findings alone. Bravo to these brave and
gusty souls.
Electrocardiographic
Manifestations of Hyperkalemia
Mattu A, et al
Am J Emerg Med
2000;18(6):721
This erudite paper with spectacular EKG tracings by practicing emergency medicine EKG aficionados and
experts is a concise review of the multiple EKG manifestations of hyperkalemia. Because hyperkalemia is a
life-threatening acute emergency and
a frequent denizen of the ED, it is imperative to be cognizant of the classic
EKG findings of this metabolic abnormality. Hyperkalemia usually occurs
in dialysis patients, but may be seen
in DKA, adrenal insufficiency, acute
digoxin poisoning, severe dehydration
with renal insufficiency, and prescribed
drugs that cause hyperkalemia. Medication-wise, especially consider spironolactone, NSAIDs, Bactrim, and ACE
inhibitors.
The peaked T waves on this EKG are striking, best described as too sharp to
sit on. But the vicissitudes and vagaries of the T wave, especially on a monitor
strip, make the EKG diagnosis of hyperkalemia tenuous at lower serum levels.
This EKG is not predictive of life-threatening hyperkalemia so one can wait for
lab confirmation, perhaps with a call to the lab tech to move things along. Of
course, bedside testing solves a whole passel of lab turnaround foibles.
InFocus
graft in his arm. Patients with hypertension, diabetes, renal failure, and a
slew of other medical problems have
many reasons to be weak, tired, and
achy, but hyperkalemia is one condition that should be high on ones
radar, even when the patient proffers
yet another weak and dizzy complaint
list.
The EKG manifestations of hyperkalemia generally parallel the serum
potassium level. Characteristic EKG
findings are promulgated in every textbook, but in my experience, a plethora
of nonspecific changes can be seen, so
dont be locked into an intense analysis
of any given pattern. I have found that
bradycardia is common, but have not
seen that emphasized. The accompanying figure provides a general overview
of potassium levels and EKG abnormalities, although there is obviously some
overlap. Potassium levels above 8.0
mEq/L generally call for immediate
action, as do the EKG abnormalities
associated with such levels, often marshalling the troops absent a critical
value call from the tardy lab. One may
be forced to treat empirically, based on
EKG evidence alone, especially in code
situations. Expect to be wrong on many
such clinical calls.
Last months column depicted a classic EKG of severe TCA overdose, with
squiggles surprisingly similar to hyperkalemia. My only pearl here is that although the QRS can be wide in TCA
overdose and hyperkalemia, its significant tachycardia and the terminal R
wave in AVR that distinctly herald TCA
toxicity. Fortunately, bicarbonate helps
both conditions.
Effects of Presentation and
Electrocardiogram on Time to
Treatment of Hyperkalemia
Freeman K, et al
Acad Emerg Med
2008;15(3):239
This is a fascinating article from
some prestigious New England university hospitals that essentially describes
standard of care for EKG-based empiric
This EKG, obviously demonstrating a slow, wide bizarre QRS pattern with an
almost sine wave appearance, is a harbinger of imminent cardiac arrest. The
potassium level is likely well over 8 mEq/L. It calls for an astute clinician who
has the chutzpah to treat empirically with the entire drug regimen aimed at
rapidly decreasing serum potassium levels and stabilizing cardiac depolarization.
Peaked T waves,
prolonged PR segment
Progressive widening of
QRS complex, sine
wave, ventricular
fibrillation, asystole,
axis deviations, bundle
branch blocks, fascicular
blocks
14 EMN
October 2009
InFocus
HYPERKALEMIA
Continued from previous page
emergency bullet for cardiac conduction issues; insulin is best for translocating potassium back into the cell;
Kayexalate has debatable efficacy and
is slow; and dialysis is the most reliable tool for removing potassium from
the body. Beta-agonists are iffy, and bicarbonate is minimally helpful. The
empiric treatment of hyperkalemia
generally can be supported under the
proper scenario, and such innocuous
interventions dont usually wreak
havoc even if ones diagnosis is off the
mark. But merely finding weakness
and an abnormal EKG can result in
rather serious consequences if the patient happens to have the rare case of
hypokalemic paralysis. The only downside of the treatment of most patients
with standard hyperkalemia regimens
is hypokalemia. Hyperglycemia, hyperosmolality, and hypercalcemia are of
little clinical consequence. These authors note that a benefit of nebulized
Comment: I learned the general treatment protocol for severe hyperkalemia, the quintessential shotgun
approach, as an intern. One aims to
push potassium back into the cell, extract it from the serum, and keep the
heart beating and contracting. There
are little data in the literature that any
specific regimen causes any specific
or quantitative result. Some question
any real value of sodium bicarbonate.
When one decides to treat hyperkalemia in the ED, a cornucopia of
therapies is simultaneously initiated.
Most interventions have few down-
sides, and are well worth the potential risks given the lethal potential for
severe untreated hyperkalemia. Importantly, all ED interventions, even
calcium, last only a few hours.
The usual ultimate treatment is hemodialysis, a necessity in the patient
with end-stage renal disease. I personally have minimal regard for nebulized
albuterol. About 40 percent experience
no benefit, and the subset likely to improve is enigmatic so far. It doesnt
seem to produce clinically significant
hypokalemia in the asthmatic patient.
In fact, we never even check potassium
under such circumstances. Albuterol
can make one very tremulous given the
fourfold dose for hyperkalemia vs.
asthma.
The Holy Grail for life-threatening
In Brief
Improving Medication
Compliance
There is no proven way to ensure patients follow medication directions for
extended periods of time, according to a
new report in the Cochrane Database of
Systematic Reviews.
Researchers led by R. Brian Haynes,
MD, PhD, of McMaster University, updated a 2005 review summarizing randomized control trials of interventions to
help patients follow prescriptions.
They found that four of 10 interventions reported in nine trials showed an
effect on adherence and at least one
clinical outcome for short-term treatments, which lasted one to three weeks.
In those short-term trials, the researchers found one intervention that
significantly improved patient adherence but did not enhance clinical outcome. Some effective approaches
included counseling and providing
written instructions.
For long-term treatments, 36 of 81
interventions reported in 69 trials were
associated with improvements in adherence, but only 25 interventions led to
improvement in at least one treatment
outcome. Some approaches with limited
success included sending reminders to patients and following up with phone calls.
Rapid Response
Teams Ineffective
Rapid response teams in hospitals do
not result in a reduced rate of cardiopulmonary arrests or deaths, according to
the December 3 issue of JAMA.
Researchers led by Paul S. Chan,
MD, of the University of Missouri,
Kansas City, examined the association
EPs: Resuscitation
Practices Lacking
An overwhelming majority of emergency physicians say resuscitation prac-
InFocus
D50, and 50 units of regular insulin, either
alone or combined therapy. The bicarbonate alone had little effect on serum
potassium. The glucose/insulin therapy
had a modest benefit, but a combination
of the two lowered serum potassium
from 6.2 to 5.2 mEq/L at 60 minutes.
Plasma osmolality was not an issue, and
there was no hypoglycemia. Bottom line:
Bicarbonate is of minimal importance,
but it seems synergistic with insulin and
may have other benefits on the milieu of
renal failure.
Allon et al (Ann Intern Med 1989;
110[6]:426) studied the effect of nebulized albuterol for acute hyperkalemia
in hemodialysis patients. This was a
randomized prospective double blind
placebo controlled trial studying either
10 or 20 mg of nebulized albuterol. The
beta-agonist lowered serum potassium
levels by approximately 0.6 to 0.9
mEq/L, with a higher dose providing the
greater effect. The hypokalemic effect
was noted within one to two hours, and
there were no adverse cardiovascular
effects. Notably, some patients had no
significant response, but the reason for
this was not known. This report was
one of the first articles to postulate a
potassium-lowering effect of nebulized
albuterol, an intervention that seems to
have gained popularity in the ED. Inhaled beta-agonist may be a good alternative when IV access is not readily
available.
The American Heart Association
recommends immediate therapy for
serum potassium levels greater than 6
mEq/L, but this is hardly a lethal potassium level, or one that cannot await laboratory confirmation. Exactly when
potassium levels become life-threatening is unknown, but treating any level
over the AHA recommendations is
reasonable. An exception to the usual
therapeutic cocktail may be severe dehydration where saline alone will quickly
lower potassium levels that are raised
secondary to pre-renal azotemia.
In these days of the omnipresent sixto infinity-hour ED waits for dialysis or
admission, the return of hyperkalemia
is not an uncommon issue for the EP
who may have moved on to other patients, content that the inpatient team
has taken control. No ED intervention
lasts more than a few hours so the clinician must be vigilant to provide continuing care after the initial bevy of
medications saved the day. I prefer to
check the potassium in about an hour to
October 2009
Questions:
1. Tall peaked T waves on the EKG are nearly 100% sensitive and specific for hyperkalemia.
True False
2. A slow, wide QRS pattern resembling a sine wave indicates impending cardiac arrest from hyperkalemia.
True False
3. It is extremely dangerous to empirically administer medication therapy for hyperkalemia without confirming the
serum potassium level.
True False
4. Nebulized albuterol is contraindicated in the presence of hyperkalemia.
True False
5. Once hyperkalemia has been treated in the ED, a repeat evaluation of potassium levels and additional therapy for
the next 24 hours is not required.
True False
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