Hyperkalemia Tutorial Hyperkalemia is the most dangerous acute

Hyperkalemia Tutorial

Hyperkalemia is the most dangerous acute electrolyte emergency

Hyperkalemia Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Weakness Increased respiratory rate Paralysis Palpitations Refer to ED lecture series and self directed workbooks

Increased Respiratory Rate Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Weakness Correct. - The symptoms of hyperkalemia are related to impaired neuromuscular transmission. Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Generalised Fatigue & Weakness Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Weakness In hyperkalemia neurologic examination may reveal diminished deep tendon reflexes or decreased motor strength Increased respiratory rate Paralysis Palpitations Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

Paralysis Which symptom is not generally an indication of hyperkalemia? Generalised fatigue Weakness The earliest findings are paresthesias and weakness, which can progress to paralysis affecting respiratory muscles. Increased respiratory rate Paralysis Press the other options to learn more or select next Palpitations Next Refer to ED lecture series and self directed workbooks

Palpitations l Which symptom is not generally an indications of hyperkalemia? Generalised fatigue Weakness In a patient with hyperkalemia cardiac examination may reveal extrasystoles, pauses or bradycardia Increased respiratory rate Paralysis Palpitations Press the other options to learn more or select next Next Refer to ED lecture series and self directed workbooks

Causes of Hyperkalemia Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma

Cushing’s Syndrome Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Correct! - Cushing’s syndrome describes the signs and symptoms of prolonged exposure to high levels of cortisol. - Cushing’s can cause hypocalceamia. Metabolic acidosis/DKA Cushing’s Syndrome Trauma Press the other options to learn more or select next Next

Pseudohyperkalemia Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Metabolic acidosis/DKA - The most common cause of hyperkalemia is haemolysis of the sample. . - Other causes of pseduohyperkalemia include leukocytosis or thrombocytosis. Cushing’s Syndrome Trauma Press the other options to learn more or select next Next

Drugs Which of the following is not one of the causes of hyperkalemia? Some drugs will cause potassium redistribution or decreased excretion. Redistributing examples; - Beta blockers - Digoxin overdoes - Succinylcholine You Drugs Renal failure Cushing’s Syndrome Decreased excretion examples; - NSAIDs - Cyclosporine - Potassium sparing diuretics Trauma ***Especially in the elderly and/or those with minor renal insufficiency*** Metabolic acidosis/DKA Press the other options to learn more or select next Next

Renal Failure Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Decreased glomerular filtration rate or a defect in tubular secretion will lead to diminished potassium excretion Metabolic acidosis/DKA Cushing’s Syndrome Trauma Press the other options to learn more or select next Next

Metabolic Acidosis/DKA Which of the following is not one of the causes of hyperkalemia? - Hyperkalemia impairs the NH 4+ You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma excretion though the proximal tubule and the reduction of NH 4+ reabsorption in the thick ascending limb. This results in reduced medullary interstitial [NH 3] 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. Press the other options to learn more or select next Next

Trauma Which of the following is not one of the causes of hyperkalemia? You Drugs Renal failure Metabolic acidosis/DKA Cushing’s Syndrome Trauma can result in hyperkalemia via cell death; - Rhabdomolysis - Internal haemorrhage - Burn - Crush - Haemolysis Press the other options to learn more or select next Next

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? Wait for blood test? Start treatment? YES! Hyper. K = 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 Loss of P Wave 5. 5 -6. 5 Widened QRS usually >8 6. 5 -7. 5 Press the other options to Learn more or select next Next

Wait for blood tests With suspected hyperkalemia should you: Perform an ECG? Wait for blood test? Start treatment? Consider the time delay for repeat blood collection if the first sample is haemolysed. An elevated result from the i. STAT may have been from an ischaemic blood draw. Press the other options to learn more or select next Next

Start treatment With suspected hyperkalemia should you: Perform an ECG? Wait for blood test? Start treatment? A tough call if you don’t know if you are facing a true hyperkalemia emergency. Select another option or select next Next

A hyperkalemia Emergency Is defined as…. A wide QRS Next

ECG Changes seen in Hyperkalemia l l l Tall Peaked T-Waves Prolonged P-R Interval Loss of P wave Widening of QRS Sine wave Next

When the T wave is bigger than the QRS think Hyperkalemia Next

Widening of the QRS now a true emergency Next

Treatment Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist Volume

Treatment – Calcium Gluconate Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Beta Agonist - 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 -20 mins). Volume ***Only give Calcium Gluconate if wide QRS*** Glucose & Insulin Bicarbonate Press the other options to learn more or select next Next

Treatment – Glucose & Insulin Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Best Option! Glucose & Insulin - Stimulates glucose pump - Glucose carries K+ in, drives Na out - Drops K by up to 1. 0 mmol/L - Works over 20 -60 minutes - Effective within 20 minutes Glucose: IV 50 g as 50% solution or 500 ml of D 10 W solution Insulin: regular IV 10 units Bicarbonate Beta Agonist Volume Press the other options to learn more or select next Next

Treatment – Bicarbonate Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Glucose & Insulin Bicarbonate - Only use if the patient is acidotic. - A good option for a patient with renal failure. - Dose is 1 -2 ampules Beta Agonist Volume Press the other options to lean more or select next Next

Treatment – β-agonist Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate - Inhaled beta agonist have been proven to be effective Glucose & Insulin - Can lower serum K+ 0. 5 – 0. 66 mmol/L - Salbutamol 5 mg can be given via a nebulised (10 -20 mg in 4 ml saline) or IV infusion (0. 5 mg) - Beware of causing tachycardia Bicarbonate Beta Agonist Volume Press the other options to lean more or select next Next

Treatment – Volume Which of the following is considered the best option for treating hyperkalemia? Calcium Gluconate Glucose & Insulin Bicarbonate Beta Agonist - Helps restore cellular Na-K gradient - Especially good in dehydrated patients - Especially bad in CHF/CRF - Beware pulmonary edema Volume Press the other options to learn more or select next Next

Steps in treating hyperkalemia l l Reverse electrical effects – treat wide QRS Calcium Gluconate Drive potassium into the cells l Glucose & Insulin l Beta agonist mask l Bicarbonate – only if acidotic l Consider saline bolus Removes potassium from the body l Forced diuresis Next l Dialysis

Summary l l Number 1 cause of hyper. K = Haemolysis Hyperkalemia = ECG Only give calcium if… wide QRS Bicarb only if… patient is acidotic Secure the ABC’s

Resources l l 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

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