Transcript Slide 1
Death by Bananas The Management of Hyperkalaemia Dr. Kiaran Flanagan, Clinical Lead Acute Medicine UHCW June 2012 Case 1 • Patient comes into ED referred by GP for high potassium of 6.7 • You see the notes in the SIFT tray • What do you do? ... How to manage • Pick up notes and PUT STICKER ON THE LIST • ABCDE • What are you likely to find? • What urgent investigation do you need to make a treatment decision? • What action would you take if – 1. Normal – 2. Abnormal What next? • History... • Examination... • Further tests • What are you looking for? What next... • Senior review? • Actions you should recommend... – Drugs – Monitoring – Admit/ Discharge – Further checks – Anticipated future actions – How will you make this happen? Case 2 • Patient on the ward • ATSP – unwell, vomiting • Day 2 of admission – post op R hemicolectomy • What do you do? What do you do? • ABCDE • Investigations? • Monitoring... Patient hyperkalaemic • What else do you look for? • What test needs to have been done? • What treatment do you need to give? Recheck K at 3 hours • Still high... • What next? – Treatment – Advice – Monitoring Recheck K at 6 hours • Still high... • What do you do? – Treatment – Monitoring – Ask for help • Who • What will you tell them and how? • What for Case 3 • Patient – Medical ALERT to Resus • Drowsy • High glucose • What do you do???? What do you do? • ABCDE • Urgent tests • What is the diagnosis? • How do you manage? Case 4 • Cardiac Arrest Call • PEA • What do you think about? Hyperkalaemia in cardiac arrest • What do you give? Case 5 • Called to ward 1, pt unwell • Low BP, low glucose, high potassium • What do you do? – Assessment – Further tests? – Working diagnosis – Treatment? Causes of Hyperkalaemia • Decreased or impaired potassium excretion – renal failure, potassium-sparing diuretics, urinary obstruction, sickle cell disease, Addison disease, and systemic lupus erythematosus (SLE) • Additions of potassium into extracellular space potassium supplements (eg, PO/IV potassium, salt substitutes), rhabdomyolysis, and hemolysis (eg, blood transfusions, burns, tumor lysis) • Transmembrane shifts (ie, shifting potassium from the intracellular to extracellular space) - acidosis and medication effects (eg, acute digitalis toxicity, beta-blockers, succinylcholine) • Factitious or pseudohyperkalemia - improper blood collection (eg, ischemic blood draw from venipuncture technique), laboratory error, leukocytosis, and thrombocytosis Causes • Ineffective elimination – Kidneys – Drugs – Endocrine • Excessive release from cells – Injury – Metabolic • Excessive intake – Lethal Injection • Pseudo ECG Changes How does it affect the heart? • Hyperkalemia results in: • Inhibition of atrial myocardial depolarization. • Slowing of heart rate. • Prolonging QRS duration; complexes may become bizarre. • Also known as atrial standstill. • Rhythm called sinoventricular rhythm. • The ECG is a poor substitute for serum potassium levels to determine the degree of abnormality ECG Changes • From reduction of P wave amplitude and prolongation of PR interval to absence of P waves altogether. • Increase of QRS duration. • Increase of QT duration. • Slowing of heart rate. • T waves become tall and spiked. • Decreased R wave amplitude ECG Changes 3 Principles of Treatment • Stabilise myocardium • Move it into cells • Increase elimination Dextrose - Insulin • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations... Calcium Gluconate • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations... Sodium Bicarbonate • How does it work? • How long for? • How do you give it? • What is the dose? • Other considerations... Calcium Resonium • Hmmm.... More controversial • Salbutamol • Furosemide Protocols • If K > 6 mmol – Calcium Resonium – Unless – Rising fast/ patient septic then treat as below • If K > 6.5 – normal ECG – Dextrose Insulin – Calcium Resonium Protocols • If K > 6.5 – abnormal ECG or • If K > 7 – Calcium Gluconate – Dex Insulin – Salbutamol – Sodium Bicarbonate – RRT Important Bits... • POTENTIAL LIFE THREATENING EMERGENCY • TREAT IF INDICATED • TRUST BUT VERIFY • RECHECK • CARDIAC MONITORING • EXPERT HELP • PREVENTION