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RLE: Managing Electrolyte Imbalances: A Case of Self-Induced Imbalance

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Questions and Rationale 21

This is the case of a 38-year-old male that was transferred to an emergency department (ED) from an another
hospital status post cardiac arrest. The patient was an inmate at a district prison who was found unresponsive in
his cell. Emergency Medical Services (EMS) was called for medical support. Minimal health information was
provided by the prison. The patient was found by EMS to be in ventricular tachycardia with a palpable pulse and
was intubated on the scene. The patient was given 150 mg of amiodarone, and transportation to an outside facility
was initiated. On laboratory evaluation at the outside hospital, the patient was noted to have a potassium level of
9. Treatment of the patient's hyperkalemia with insulin, beta-agonists, and calcium was initiated. After initial
resuscitation, the patient was transported to our ED. While en route, the patient experienced an episode of
pulseless ventricular tachycardia, requiring two episodes of cardioversion. Return of spontaneous circulation was
achieved prior to ED arrival.

Questions:

1. The patient’s potassium level is: Encircle one (1 pt)


a. High
b. Low
2. Why is the patient given (2 pts each, provided references)
a. Insulin:
A combination of IV insulin dose of 10 units plus 25 g of dextrose reliably lowers the serum
potassium level by 1 mEq/L (mmol/L) within 10–20 minutes and the effect lasts about 4-6
hours.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377764/#:~:text=A%20combination%20of
%20IV%20insulin,14%2C%2018%E2%80%9321%5D.

b. Beta-agonist
Albuterol is an adrenergic agonist that has an additive effect with insulin and glucose, which
can in turn help transfer potassium into the intracellular space. This agent reduces the serum
potassium level by 0.5-1.5 mEq/L. When fluid overload is involved, it can be very helpful in
patients with renal failure.

https://www.medscape.com/answers/240903-13536/which-medications-in-the-drug-class-beta-
adrenergic-agonists-are-used-in-the-treatment-of-hyperkalemia#:~:text=Albuterol%20is%20an
%20adrenergic%20agonist,when%20fluid%20overload%20is%20concern.

c. Calcium
Intravenous calcium gluconate should be given to patients with hyperkalemia and typical ECG
alterations. Acutely decreased potassium by intravenous glucose insulin, a nebulizer beta2
agonist, or both.

https://www.aafp.org/afp/2006/0115/p283.html#:~:text=Patients%20with%20hyperkalemia
%20and%20characteristic,be%20given%20intravenous%20calcium%20gluconate.&text=Acutely
%20lower%20potassium%20by%20giving,agonist%20by%20nebulizer%2C%20or
%20both.&text=Total%20body%20potassium%20should%20usually,sodium%20polystyrene
%20sulfonate%20(Kayexalate).
In the ED, vitals were as follows: blood pressure 90/50, heart rate 143 beats per minute, respiratory rate 13
breaths per minute, oxygen (O 2) saturation 99%, temperature 35.4 Celsius (C). An electrocardiogram (ECG) was
performed, which documented ventricular tachycardia at a rate of 140 without ST segment or T wave changes. On
exam, the patient was noted to be intubated. Head, ears, eyes, nose, and throat (HEENT) exam revealed 3
millimeter (mm) pupils that were sluggishly reactive to light and equal bilaterally and an endotracheal tube at 25
centimeters (cm) at the teeth. The remainder of the HEENT exam was unremarkable. Neck exam revealed a
cervical collar in place with no cervical spine step-off noted. Cardiovascular exam revealed a heart rate of 140
beats per minute with palpable distal pulses. Lungs were clear to auscultation bilaterally. Abdomen was soft with
good bowel sounds and no evidence of distension. On neurological exam, the patient was noted to be sedated
with a Glasgow coma scale (GCS) of 3T.

3. Is the ECG result expected of his case? Encircle one (1 pt)


a. Yes
b. No
4. What is the rationale behind your answer? (2pt, provided references)
T wave should look tall ”tented” or peaked because ventricular tachycardia is expected in the
case of the patient.

https://www.sciencedirect.com/topics/medicine-and-dentistry/t-wave-amplitude

The patient had blood sent to the lab for multiple studies. The patient's complete blood count (CBC) revealed a
white blood cell count of 23.6 thou/cu mm, a hemoglobin of 14.7 g/dL, a hematocrit of 45.5%, her and a platelet
count of 181 thou/cu mm. His basic metabolic panel revealed a sodium of 143 mmol/L, a potassium of 8.7 mmol/L,
a chloride of 120 mmol/L, a bicarbonate of 16 mmol/L, a BUN of 22 mg/dL, a creatinine of 1.06 mg/dL, and a
glucose of 191 mg/dL. Arterial blood gas revealed a pH of 7.06, pCO 2 of 58 mmHg, and pO2 of 77 mmHg. Cardiac
markers and urinalysis were both unremarkable. A urine drug screen was positive for benzodiazepines.

5. Interpret that patient’s ABG result: (5 pts)


Mixed acidosis/Global acidosis

pH - 7.06 – Acidosis
pCO2- 58mmHg – Acidosis
HCO3- 16mmol/L - Acidosis

6. How is this related to the patient’s case? (2 pts, provided references)


It encourages potassium to pass from the intracellular compartment to the extracellular
compartment, resulting in a high amount of potassium that causes hyperkalemia to occur in
the patient.

https://acutecaretesting.org/en/journal-scans/on-the-relationship-between-potassium-and-acid-base-
balance#:~:text=A%20frequently%20cited%20mechanism%20for,of%20potassium%20and%20hydrogen
%20ions

The patient's emergency department management began with initial stabilization. Due to his persistent ventricular
tachycardia, the patient was given another bolus of amiodarone upon arrival and a subsequent amiodarone
infusion was started. Due to low mean arterial pressures, two liter of normal saline was given intravenously, a right
subclavian central venous line was placed, and a left radial arterial line was placed. A levophed drip was started at
0.1 mcg/kg/min and titrated to maintain a mean arterial pressure (MAP) of 65 for pressure support. Treatment for
hyperkalemia was readministered concurrently, consisting of insulin, beta-agonists and kayexalate. Chest X-ray
revealed clear lungs with radio paque capsules in the fundus of the stomach. Over the next thirty minutes, the
patient's rhythm converted to normal sinus rhythm and slowed to around 70 beats per minute. Repeat potassium
lab draw revealed persistently elevated potassium level of 8.3 mmol/L, and hyperkalemia treatment was repeated.
At this point, nephrology was consulted for emergent dialysis, and the medical intensive care unit (MICU) was
notified for admission. We later found out, from the MICU team, that the patient had an
esophagogastroduodenoscopy (EGD) performed to remove the unknown pills from the patient's stomach, which
were found to be potassium chloride pills. After removal of the pills and multiple episodes of dialysis, the patient
stabilized and was weaned from pressure and ventilator support. The patient's leukocytosis was believed to be a
stress response as the MICU team was never able to determine a source of infection; however, the patient
remained on-broad spectrum intravenous antibiotics over the course of his stay.

7. What is the role of kayexalate? (2 pts, provided references)

Kayexalate binds itself to potassium in your digestive tract. This helps prevent your body from
absorbing too much potassium. It is also used to treat high levels of potassium in the blood,
also called hyperkalemia.

https://www.drugs.com/mtm/kayexalate.html#:~:text=Kayexalate%20binds%20itself%20to
%20potassium%20in%20your%20digestive,of%20potassium%20in%20the%20blood%2C%20also
%20called%20hyperkalemia

8. What is the role of dialysis in this case? (2 pts, provided references)

dialysis is necessary to help regulate potassium. Between dialysis treatments, however,


potassium levels rise and high-potassium foods must be limited.

https://www.davita.com/diet-nutrition/articles/basics/potassium-and-chronic-kidney-disease

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