deadly electrolyte emergencies what is the number one...

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SEMPA 2019

Deadly Electrolyte Emergencies

Corey M. Slovis, M.D.Vanderbilt University Medical Center

Metro Nashville Fire DepartmentNashville International Airport

Nashville, TN

What is the number one cause of Hyperkalemia?

The Most Common Cause of Hyperkalemia is . . .

You and Me!

Hyperkalemia is the Most Dangerous Acute Electrolyte Emergency

HyperK = ECG

ECG Changes Serum Level

Loss of P Wave 6.5 - 7.5

Widened QRS usually > 8

Tall Peaked T 5.5 - 6.5

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What are the 5 ECG Changes Seen in Hyperkalemia

• Tall Peaked T-Waves

• Prolonged P-R Interval

• Loss of P Wave

• Widening of QRS

• Sine Wave

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Hyperkalemia5 “Benign” Causes

• ACE Inhibitors/ARBs

• Potassium Supplements

• NSAIDS, COX-2 Inhibitors

• Potassium Sparing Diuretics

• Bactrim

– Especially in the elderly

– Especially in those with mild renal insufficiency

When do you use calcium for Hyperkalemia?

• Calcium Tricks Cells

• Calcium Does NOT Affect Levels

Calcium in Hyperkalemia

• Tricks Cell

• Recreates Electrical Gradient

• Temporary, lasts only 5-20 minutes

• Dose is 5-20 cc CaCl IV

• Potentially Dangerous

Be sure before using!

CaCl Ca Gluconate

X 1,000,000

CaCl

• 13.6 meq/10cc

• More sclerosing

• Adults

• Emergency

• IV Push

• 4.6 meq/10cc

• Less sclerosing

• Kids

• Chronic

• Slow Infusion

Ca Gluconate

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NEJM 2012;366:1824 NEJM 2012;366:1824

Only give calcium if . . .

there is a wide QRS

A 50 yo patient is hypotensive and bradycardicIs Atropine or Transcutaneous Pacing the best rx?

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• Wide QRS

• Sine Wave

HyperkalemiaIndications for CaCl

• Bradycardia and/or Heart Block

• Wide QRS

• Sine Wave



Symptomatic Bradycardia5 Rule Outs

• Abnormal VS: Hypoxia, Hypothermia

• Ischemia/Infarction

• Elevated ICP

• Beta Blocker-Calcium Blocker (and other) ODs

• Hyperkalemia

STEMI?

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JAMA Int Med 2018;178:133-4

JAMA Int Med 2018;178:133-4

JAMA Int Med 2018;178:133-4

but…

STEMI = check K if RF(or really big T waves)

Time = Muscle

West J Emerg Med 2017;18:963-71

What ECG changes predict patient decompensation in HyperKalemia?

• 188 patients serum K ≥ 6.5 meq/L ( x = 7.1)

• Observational study, Brown University

• ECGs within 60 min of serum (mean = 18 min)

• Hemolyzed samples excluded

• Peaked Ts, P-R , QRS , Bradycardia, Junctional

ECG Predictors of Adverse Events

• QRS prolongation most common predictor- Seen in 79% of pts with adverse events- Average QRS 152 msec

• Bradycardia second most common predictor- Seen in 60% of pts with adverse event

• 86% of patients had > 1 ECG abnormality


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No patient with only peaked Ts or prolonged P-R duration had an

adverse event


ECG Changes and HyperKalemiaTake Homes

• Widened QRS and Bradycardia in Hyperkalemia portends disaster

• Tall peaked T waves do NOT

• Do not use calcium for those patients who merely have peaked T waves and/or a prolongation of the P-R interval

How effective is bicarbonate in Hyperkalemia?

Bicarbonate For Hyperkalemia

(2) H +

(3)K+

(1) HCO3—

(3) K+ will move intracellularly to maintain the cell’s electroneutrality.

(1) As HCO3—

is added to serum

(2) H+ from cell will move extracellularly to buffer alkali load

Bicarbonate is Great in Hyperkalemia

but only if:

The Patient is Acidotic

Bicarb

Epi

Glucose/Insulin

HD

Amer J Kidney Disease 1991;18:421-440

Potassium Lowering Effects

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Steps in Treating Hyperkalemia

• Reverse electrical effects

• Drive potassium into the cells

• Remove potassium from the body

STEP 1:Treating Hyperkalemia

Calcium Chloride

• 5 – 10 cc of 10% CaCl

• No more than 20 ccs

Reversing Electrical Effect


Glucose and Insulin• 2 amps of D50%• 10 units regular insulin

Beta Agonist Mask

Consider Saline Bolus• 200 cc NSS

Drive K Intracellularly

Bicarbonate if acidotic• 1 – 2 amps of NaHCO3

• 8.7% of 219 patients got hypoglycemic post therapy for hyperkalemia

• 2.3% had glucose values < 40

• Almost all severe patients had CRF or HD

J Hosp Med 2012;7:234-47


Forced Diuresis• 250 - 500cc/hr NaCl• Supplemented with Lasix

Ion Exchange Resin• 30 – 60G Kayexalate

Dialysis• Hemodialysis &/or Peritoneal

Removing K from the Body

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Calcium Wide QRS/Brady/HB

Hyperkalemia Treatments5 Key Concepts

Bicarb Acidosis

Glu/Insulin Hypoglycemia

Beta Agonists Benign and Easy

Volume Selected Cases

Hypokalemia

Hypokalemia - 5 Most Common Causes

• Chronic ETOH or Malnutrition

• Decreased Intake

• Increased losses

• Intracellular Shift

– Urine• Diuretics (Non K, Non Mag Sparing)

• Vomiting (K lost 2º to resultant alkalosis)

– GI• Chronic Diarrhea or Laxative Abuse

• Hyperventilation or Metabolic Alkalosis

5 ECG Changes Hypokalemia

• Loss of T Wave

• U Waves

• Prolonged Q-T

• Torsades, VT, VF

• Diffuse, Nonspecific ST and T Wave Changes

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Annals of EM 1990

When is Hypokalemiaan Emergency?

QTc = 500 mSec

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Beware Prolonged Q-T

Hypokalemia Severe or Refractory Hypokalemia Always Equals?

Hypomagnesaemia

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American Heart J 1985

Serum Magnesium Levels

• Inaccurate “Snap Shot”

• Expensive

• Silly

HypoK = HypoMag

What dosing of Magnesium makes you an expert in hypokalemic patients?

Dose of Magnesium

• Loading Dose

• 1-2 Grams over 0-60 minutes… except eclampsia

• Maintenance Dose

• 0.5 Gram per hour

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Load with 1 – 2 grams over 0 – 60 minutes

Maintenance infusion is 0.5 – 1 gram per hour

0.5 Grams/hour

Magnesium Dosing A normal sized patient has a K

of 2.9 meq/L. What is their approximate

total body deficit?

Total Body Potassium Deficit:

Use MORE Than You Think

Every 0.3 meq/l fall below 3.5 meq/l requires:

100 meq of KCL

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• You can give IV KCL at 10 – 20 meq/hr

• Faster than 10 meq/hr peripherally may burn

• Faster centrally may be cardiotoxic

• Oral dosing is 20-60 meq via liquid

• 10-20 meq in pills or 25 meq in powder

Administering Potassium

Chest 2004;125:404-9

J Pain 2008;9:722-31

Patients prefer diet modification for potassium supplementation over pills

High potassium containing foods can replacepotassium supplementation in patients on

potassium losing diuretics

High K foods can raise K from 3.31 meq/L to 4.67 meq/L by diet changes alone

Oral Potassium Repletion

• Baked potato 22 meq

• Tomato sauce (4 oz) 12 meq

• Banana 12 meq

• Avocado (1/4) 10 meq

• Tomato 7 meq

• Salt substitute 5 meq

Chest 2004;125:404-9

Juices for Potassium Repletion8 ounce servings

• Tomato Juice 14.1 meq

• V8 Juice 11.0 meq

• Orange Juice 10.6 meq

• Grapefruit Juice 9.2 meq

• Whole Milk 9.1 meq

I used to say:Hypo K = Hypo Mag

Now I also say Hypo K =Orange Juice, Potatoes, Bananas, Avocados and

Tomatoes

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Why is Hypokalemia the number one cause of

unexpected death in DKA?

Five Therapies to Consider in DKA

• Volume

• Insulin

• Potassium

• Bicarbonate

• Phosphate

......................

Treating DKADriving Kinto the Cell

• Glu + Insulin

• Bicarb

• Volume

• Beta Agonist

• Magnesium

•

•

•

•

• –

Usually Asymptomatic

Hypokalemia Treatments5 Key Concepts

Repletion takes more than you think

10 – 20 meq/hr IV is safe

Use PO Too, especially foods

HypoK = HypoMg

SummaryNumber One Cause of HyperK=

NOT

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HyperK = ECGOnly give calcium if . . .

there is a wide QRS

• Wide QRS

• Sine Wave



Bicarb only if . . . Acidotic

HypoK = HypoMagIf you give K . . .

You must give Mag

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The Usual Hourly Infusion of Magnesium is…

0.5 grams/hr.

SECURE THE ABC’SSECURE THE ABC’S

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