Hyperkalemia Tutorial. Which symptom is not generally an indication of hyperkalemia? Refer to ED...

Hyperkalemia Tutorial

Hyperkalemia is the most dangerous acute electrolyte emergency

Which symptom is not generally an indication of hyperkalemia?

Refer to ED lecture series and self directed workbooks

Hyperkalemia

Generalised fatigue

Weakness

Increased respiratory rate

Paralysis

Palpitations



Increased Respiratory Rate

Generalised fatigue

Weakness


Paralysis

Palpitations

Correct.- The symptoms of hyperkalemia are related to impaired neuromuscular transmission.

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Generalised Fatigue & Weakness

Generalised fatigue

Weakness


Paralysis

Palpitations

In hyperkalemia neurologic examination may reveal diminished deep tendon reflexes or decreased motor strength

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Paralysis

Generalised fatigue

Weakness


Paralysis

Palpitations

The earliest findings are paresthesias and weakness, which can progress to paralysis affecting respiratory muscles.

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Which symptom is not generally an indications of hyperkalemia?


Palpitations

Generalised fatigue

Weakness


Paralysis

Palpitations

In a patient with hyperkalemia cardiac examination may reveal extrasystoles, pauses or bradycardia

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Causes of Hyperkalemia

Which of the following is not one of the causes of hyperkalemia?

You

Drugs

Renal failure

Metabolic acidosis/DKA

Trauma

Cushing’s Syndrome



You

Drugs

Renal failure


Trauma


Correct!- Cushing’s syndrome describes the signs and symptoms of prolonged exposure to high levels of cortisol.

- Cushing’s can cause hypocalceamia.

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Pseudohyperkalemia


You

Drugs

Renal failure


Trauma


- The most common cause of hyperkalemia is haemolysis of the sample..

- Other causes of pseduohyperkalemia include leukocytosis or thrombocytosis.

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Drugs


You

Drugs

Renal failure


Trauma


Some drugs will cause potassium redistribution or decreased excretion.

Redistributing examples;

- Beta blockers

- Digoxin overdoes

- Succinylcholine

Decreased excretion examples;

- NSAIDs

- Cyclosporine

- Potassium sparing diuretics

***Especially in the elderly and/or those with minor renal insufficiency***

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Renal Failure


You

Drugs

Renal failure


Trauma


Decreased glomerular filtration rate or a defect in tubular secretion will lead to diminished potassium excretion

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Metabolic Acidosis/DKA


You

Drugs

Renal failure


Trauma


- Hyperkalemia impairs the NH4+ excretion though the proximal tubule and the reduction of NH4+ reabsorption in the thick ascending limb. This results in reduced medullary interstitial [NH3] and a decrease in net renal acid secretion.

- This is a common feature in diabetes and a number of other conditions associated with underproduction of renin or aldosterone.

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Trauma


You

Drugs

Renal failure


Trauma


Trauma can result in hyperkalemia via cell death;

- Rhabdomolysis

- Internal haemorrhage

- Burn

- Crush

- Haemolysis

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Hyperkalemia

With suspected hyperkalemia should you first:

Perform an ECG?

Wait for blood test?

Start treatment?

Hyperkalemia = ECG

With suspected hyperkalemia should you first:

Perform an ECG?


Start treatment?

YES! HyperK = ECG

If a patient arrives with a K+ of 9 mmol/L is it an emergency? Was it a haemolysed sample?

If they have a sine wave on ECG, then yes.

ECG Changes Serum Level

Tall Peaked T 5.5-6.5

Loss of P Wave 6.5-7.5

Widened QRS usually >8Next

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Wait for blood tests

With suspected hyperkalemia should you:

Perform an ECG?


Start treatment?

Consider the time delay for repeat blood collection if the first sample is haemolysed. An elevated result from the iSTAT may have been from an ischaemic blood draw.

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Start treatment

With suspected hyperkalemia should you:

Perform an ECG?


Start treatment?

A tough call if you don’t know if you are facing a true hyperkalemia emergency.

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A hyperkalemia EmergencyIs defined as….

A wide QRS

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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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When the T wave is bigger than the QRS think Hyperkalemia

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Widening of the QRS now a true emergencyNext

Treatment

Which of the following is considered the best option for treating hyperkalemia?Calcium Gluconate

Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

Treatment – Calcium Gluconate


Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

- Only use in a true hyperkalemia emergency (widen QRS).

- Tricks the cell by re-creating the electrical potential, narrowing the QRS.

- Does not affect the potassium level and is only temporary (5-20mins).

***Only give Calcium Gluconate if wide QRS***

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Treatment – Glucose & Insulin


Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

Best Option!- Stimulates glucose pump

- Glucose carries K+ in, drives Na out

- Drops K by up to 1.0mmol/L

- Works over 20-60 minutes

- Effective within 20 minutes

Glucose: IV 50g as 50% solution or 500ml of D10W solution

Insulin: regular IV 10 units

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Treatment – Bicarbonate


Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

- Only use if the patient is acidotic.

- A good option for a patient with renal failure.

- Dose is 1-2 ampules

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Treatment – β-agonist


Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

- Inhaled beta agonist have been proven to be effective

- Can lower serum K+ 0.5 – 0.66mmol/L

- Salbutamol 5mg can be given via a nebulised (10-20mg in 4ml saline) or IV infusion (0.5mg)

- Beware of causing tachycardia

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Treatment – Volume


Glucose & Insulin

Bicarbonate

Beta Agonist

Volume

- Helps restore cellular Na-K gradient

- Especially good in dehydrated patients

- Especially bad in CHF/CRF

- Beware pulmonary edema

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Steps in treating hyperkalemia

Reverse electrical effects – treat wide QRS Calcium Gluconate Drive potassium into the cells

Glucose & Insulin Beta agonist mask Bicarbonate – only if acidotic Consider saline bolus

Removes potassium from the body Forced diuresis Dialysis Next

Summary

Number 1 cause of hyperK = Haemolysis Hyperkalemia = ECG Only give calcium if… wide QRS Bicarb only if… patient is acidotic

Secure the ABC’s

Resources Journal of the American Society of Nephrology (http://jasn.asnjournals.org/content/20/2/251.full ) Medscape (http://emedicine.medscape.com/article/766479-overview ) USCEssentials 2009-04 ‘Kyper K in 20 min’ Dr Corey Slovis http://enotes.tripod.com/hyperkalemia.htm

http://jasn.asnjournals.org/content/20/2/251.full

http://jasn.asnjournals.org/content/20/2/251.full

http://emedicine.medscape.com/article/766479-overview

http://emedicine.medscape.com/article/766479-overview

http://enotes.tripod.com/hyperkalemia.htm

http://enotes.tripod.com/hyperkalemia.htm

Hyperkalemia Tutorial. Which symptom is not generally an indication of hyperkalemia? Refer to ED...

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