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RLEFandECS Garlitos Roanne
RLEFandECS Garlitos Roanne
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:
Insulin is given because much like glucose, it encourages potassium movement back
into the cells from the extracellular space, thus decreasing the potassium levels
needed since the patient has hyperkalemia.
Li,T. & Vijayan, A. (2014, June). Insulin for the treatment of hyperkalemia: a double-edged sword?
Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377764/#:~:text=Insulin%20shifts%20potassi
um%20into%20cells,serum%20potassium%20levels%20%5B16%5D
b. Beta-agonist
Beta agonists activates membrane-bound Na/K-ATPase and cause potassium levels shift into cell. Too
much use of this medication if not being controlled will lead to hypokalemia.
Mushiyakh, Y. et al. (2011). Treatment and pathogenesis of acute hyperkalemia. Retrieved from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714047/
Ng, K. & Lee, C. (2017, February 16). Updated Treatment Options in the Management of
Hyperkalemia. Retrieved from: https://www.uspharmacist.com/article/updated-treatment-
options-in-the-management-of-hyperkalemia
c. Calcium
Without lowering potassium level, calcium directly antagonizes the myocardial effects
of hyperkalemia. It antagonizes the cardiotoxicity of hyperkalemia by stabilizing the
cardiac cell membrane against undesirable depolarization. This is done by reducing
the threshold potential of cardiac myocytes, thereby restoring the normal gradient of
the hyperkalemia-distorted resting membrane potential. Calcium protects the
myocardium and cardiac membranes from hyperkalemia's deleterious effects.
In the ED, vitals were as follows: blood pressure 90/50, heart rate 143 beats per minute, respiratory rate 13
breaths per minute, oxygen (O2) 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.
Lederer, E. (2020, April 09). What do ECG findings indicate in hyperkalemia (high serum potassium
level). Retrieved from: https://www.medscape.com/answers/240903-11014/what-do-ecg-
findings-indicate-in-hyperkalemia-high-serum-potassium-level
Sims, D. &Sperling, L. (2005, May 17). ST-Segment Elevation Resulting From Hyperkalemia. Retrieved
from: https://www.ahajournals.org/doi/10.1161/01.CIR.0000165127.41028.D1
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,
pCO2 of 58 mmHg, and pO2 of 77 mmHg. Cardiac markers and urinalysis were both unremarkable. A
urine drug screen was positive for benzodiazepines.
It’s Mixed Acidosis because partial pressure of carbon dioxide is much higher than
concentration of hydrogen carbonate in the blood.
pH - 7.06 – Acidosis
pCO2- 58mmHg – Acidosis
HCO3- 16mmol/L - Acidosis
Higging, C. (2013, October). On the relationship between potassium and acid-base balance. Retrieved
from: https://acutecaretesting.org/en/journal-scans/on-the-relationship-between-potassium-
and-acid-base-
balance#:~:text=A%20frequently%20cited%20mechanism%20for,of%20potassium%20and%20h
ydrogen%20ions.
In the digestive tract, it binds to potassium, which allows the body not to consume too much
potassium. This is a standard treatment for hyperkalemia or elevated blood potassium levels.
The patient's blood is filtered and most importantly, the elevated potassium is regulated in
order for the patient to return to normal levels. Dialysis is performed when a person has
kidney issues, because pharmacological treatment alone is not sufficient to safely decrease
the level of potassium.
Garth, D. (2019, August 06). What is the role of dialysis in the treatment of hyperkalemia (high serum
potassium level). Retrieved from: https://pubmed.ncbi.nlm.nih.gov/17897250/
Putch, N. & Allon, M. (2007). Management of hyperkalemia in dialysis patients. Retrieved from:
https://pubmed.ncbi.nlm.nih.gov/17897250/#:~:text=Abstract,used%20to%20stabilize%20the%20myoc
ardium.