Here is the script of what happened with this patient: (Source: Movin' Meat... Thanks to ER Dr Shadowfax...)
"The tech, as per protocol, dropped the ECG on my desk within three minutes of its being completed, along with the chart. He was visibly excited. I glanced at the ECG and the triage note. In the standard terse nursing verbiage, it read "CC: Ground Level Fall. Too weak to get out of bed. No injury reported. No other complaints." There was an included prior ECG, which was normal. Today's looked like this: (see ECG above)
"Should
I call the cath lab?" the tech asked. We pride ourselves in having the
best door-to-dilation time in the region, and it's a key focus of our
department protocols that patients with an "Acute MI" or
heart attack need to be expedited to the cath lab. The tech had seen the
computer interpretation of "ACUTE MI" and was rarin' to go.
I have
learned not to trust the computer. The only thing it can reliably interpret is
"Normal" and even then it is sometimes wrong.
So, as
several of the commenters correctly guessed, I ordered a stat chemistry panel,
and the serum potassium was resulted at 8.5 (normal = 3.5-4.5), which should
not be surprising because, once I took the drastic step of meeting and
interviewing the patient, he has kidney failure and is dialysis dependent. He
was too weak to get out of bed for dialysis and so had missed his appointment,
which was part of the reason his potassium was elevated. The other part? I'll
get to that.
So, hyperkalemia (medicalese
for "high potassium") is one of those things that is a true
emergency, that can be immediately lethal if not treated, and one of the few
things that really gets an ER doctor moving. Potassium is involved in
maintaining the electrical gradient which allows muscle and nerve cells to
function -- excessive potassium in the bloodstream poisons the ability of these
cells to operate normally. This accounts for the patient's generalized
weakness. The Bad Thing that can happen is that the heart muscle can be
affected -- in this case, the heart muscle was no longer contracting briskly in
unison over the usual 100 milliseconds or so, but rather contracting sluggishly
over a period of 200 msec; you can see how wide and ugly the spikes (QRS complex)
are on the above ECG. It was still pumping OK, but the risk is that this makes
the heart very vulnerable to arrhythmia, that any minor disruption, like a
premature beat, could induce irrecoverable ventricular
fibrillation.
Fortunately
for adrenaline junkies like me, there is an antidote: a cocktail of Calcium,
Sodium Bicarbonate, and insulin, which can very quickly mitigate the effects of
hyperkalemia. the bicarb and insulin activate ion pumps which move the
potassium inside of cells, which temporarily "hides" the excess
potassium from the heart. Calcium buffers the heart cell membranes and
stabilizes them from the ill effects of the potassium. It's extremely
gratifying. It doesn't fix the problem, but generally buys you enough time to
get the patient to dialysis, which will remove the potassium from the
bloodstream. Calcium works fastest and should always be given first in these
situations. Here's how it worked for us:
And the
after-treatment ECG:
Notice the
nice narrow QRS complexes. Much better looking. And off he went for emergency
dialysis.
And as for
the "why" -- well, he had a dedicated and caring wife. She was very
concerned about the general decline in his health since he had been on
dialysis, and that in particular he was losing weight and malnourished because
he no longer had the appetite he once did. So over the weekend, she went and
got him some really nutritious vegetable juice -- V8.
Chock full
o' potassium. 470 mg per serving. Sheesh"
Source: Movin' Meat....(reblogged) thanks Shadowfax
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