Great case.

[DrQuinn]

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Little old lady, comes in at 0730 to our free standing ED.... weak, HR in 30s, EMS gives 0.5 atropine.

EKG widened ugly QRS, bradycardic in 40s. Pt with hx of CHF, on digoxin, spironolactone.

K comes back 9.5. Cr 1.1. Treated, QRS narrows, looks much better, dig comes back 3.77.

Repeat Ks come back > 9.0, now with a dig level of 3.77. We don't have digibind, either.

Transferred to MICU, still alive.

Weird but very cool case. Gave the calcium by the way, she is still alive.

Q

 

[BADMD]

, dig comes back 3.77... We don't have digibind, either.... Gave the calcium by the way, she is still alive.

Q

No Dig Fab? Eek? Might want to see if y'all can fix that.

The stone heart thing is totally overblown. Very little evidence for it.

Scary case. I've only seen a few Dig patients that were really that toxic.

 

[DrQuinn]

No Dig Fab? Eek? Might want to see if y'all can fix that.

The stone heart thing is totally overblown. Very little evidence for it.

Scary case. I've only seen a few Dig patients that were really that toxic.

Yeah, we just opened our freestanding ED July 1st, so still going through some growing pains. I already emailed out the med director. Yeah no digibind. Ugh.

I have heard the stone heart thing was overblown but did know one doc in my residency who anecdotally knew of an actual case.

My sphincter did tighten a but as I was typing up her chart when the dig came back, I was like "oh $hit I gave calcium" but obviously she is doing fine. MICU called me, K down to 5.5, EKG normal now, pt much better after only digibind and what I gave here. Weird case, great, though, to start a Sat morning shift with.

The toxicologist called (I called Poison Control), and he said "no way the K is that high, its got to be hemolyzed." Funny. EKG c/w it and labs x 3 K >9.0. Cool case. See if an FP res wants to write it up with me (no longer academic).
Q

 

[BADMD]

A K of > 9 does seem awfully high for a Cr of 1.1 and a Dig of 3.77. The chronic ones usually present with a lower K and higher Cr. It almost brings up the question of was this an acute ingestion.

If/when you write it up, try to find out the last time she took dig and if she could have just ODed on potassium. Dig has a multicompartment redistribution, so measurement is only accurate about 6 hours after the last dose.

The chronics usually slowly build up dig levels and slowly move potassium extracellularly. Until they hit frank renal failure, they tend to excrete potassium fairly well. Many of the chronicly toxic patients I've seen actually have normal to low potassium concentrations with total body depletion. The rest have moderately high Ks (5-6 range).

Definitely an odd one that makes you say "hmm...."

 

[DoctorMedic]

good case, def a way to start off your shift huh.

 

[DrQuinn]

Definnitely weird for a chronic ingestion, they typically aren't hyper K. However, I spoke with the ICU resident, pt had increased her spironolactone last week, and was told by PCP to double her K dose this week as it was low last week. AND she had outpatient surgery yestrday (neglected to mention but not that important to acuity of the case), and who knows maybe the anesthetic gave her a bump in her K as well as decr GI motility allowing her to absorb more K, who knows. Definitely a great case though. REALLY ugly EKG, wish I could scan it and upload it.
Q

 

[DoctorMedic]

Definnitely weird for a chronic ingestion, they typically aren't hyper K. However, I spoke with the ICU resident, pt had increased her spironolactone last week, and was told by PCP to double her K dose this week as it was low last week. AND she had outpatient surgery yestrday (neglected to mention but not that important to acuity of the case), and who knows maybe the anesthetic gave her a bump in her K as well as decr GI motility allowing her to absorb more K, who knows. Definitely a great case though. REALLY ugly EKG, wish I could scan it and upload it.
Q

can always take a picture of it

 

[Apollyon]

The toxicologist called (I called Poison Control), and he said "no way the K is that high, its got to be hemolyzed."

See, this kind of bugs me (a lot), when someone says what it "must" be. BADMD is a trained toxie, and southerndoc did a lot of work in it, and they look at what is going on, but don't throw the baby out with the bathwater. I say the K+ is 9, you say it must be hemolyzed, I say it's not - the issue is dead (unlike the patient, thank heavens).

You make the scenario fit the patient, not the other way around. No matter what, some patients will break the rules, or will really have two problems at the same time (like the pt I had as a resident with a gushing vag bleed - and an acute PE - in the words of Dave Barry, I Am Not Making This Up).

 

[southerndoc]

We had a case recently (not my patient) where a patient had a K of 7.5 with a normal creatinine. Turns out they were using a salt substitute like crazy trying to reduce their sodium level to help lower their blood pressure.

The biggest thing with any patient is to look at the patient and the clinical picture. In this case, the K fits since the patient was bradycardic, had a widened QRS, etc. If this patient had a normal EKG, then I would've leaned more toward hemolysis, but with such a high K like that, the lab will always detect the hemolysis and report it.

 

[kungfufishing]

That is funny - I had one not too unlike this, elderly guy with a wife who was so worried about his potassium getting low she had him take extra potassium every time he took all of his other meds, including digoxin. I don't think she was trying to murder him, but she came close.

 

[NateintheED]

We had a case recently (not my patient) where a patient had a K of 7.5 with a normal creatinine. Turns out they were using a salt substitute like crazy trying to reduce their sodium level to help lower their blood pressure.

The biggest thing with any patient is to look at the patient and the clinical picture. In this case, the K fits since the patient was bradycardic, had a widened QRS, etc. If this patient had a normal EKG, then I would've leaned more toward hemolysis, but with such a high K like that, the lab will always detect the hemolysis and report it.

I too had a case like this a couple years ago. 60ish year old guy w/ NIDDM and a little bit of CRI (creatinine 2.0) using a salt substitute. Came in because he was too weak to get out of bed, and wife called 911. Unable to move extremities against gravity on arrival. EKG looked like a sine wave, K was 10.1. Did all the stuff for K, watched the EKG narrow over about 40 minutes, and he waved to me on the way to the ICU w/ a repeat K of 8.4. Otherwise, vitals were stable the entire time. Pretty cool for an EM intern!

 

[Groove]

Thanks for the case and resultant discussion. It would be nice if we could have more of these on a semi regular basis... Teaching cases are helpful, especially with all the attendings discussing their thoughts on management.

 

[zinjanthropus]

Thanks for the case and resultant discussion. It would be nice if we could have more of these on a semi regular basis... Teaching cases are helpful, especially with all the attendings discussing their thoughts on management.

completely agree

 

[docB]

Thanks for the case and resultant discussion. It would be nice if we could have more of these on a semi regular basis... Teaching cases are helpful, especially with all the attendings discussing their thoughts on management.

We should try to do more of these even though it takes time away from my endless therapeutic bitching. We do have a Journal Club sub forum too that is under utilized.

 

[hyperbaric]

Thanks for the case and resultant discussion. It would be nice if we could have more of these on a semi regular basis... Teaching cases are helpful, especially with all the attendings discussing their thoughts on management.

Yep, I love the cases.

We should try to do more of these even though it takes time away from my endless therapeutic bitching. We do have a Journal Club sub forum too that is under utilized.

I'll play.

 

[DrJosephKim]

Interesting case...

Wow, you don't have Digibind? Then what do you do in those situations?

 

[leviathan]

Please post more, guys/girls. Loving it!

 

[Stitch]

We should try to do more of these even though it takes time away from my endless therapeutic bitching. We do have a Journal Club sub forum too that is under utilized.

I'd love to see more good case discussions. I've got a few, but they're all peds cases, so I don't know if they'd be very helpful for anyone here.

 

[EM2BE]

I'd love to see more good case discussions. I've got a few, but they're all peds cases, so I don't know if they'd be very helpful for anyone here.

I'm sure there are several here that deal with peds too. I would love to hear them myself (some of the rotations I have done have no Peds EM, so we do all).

 

[DrQuinn]

Interesting case...

Wow, you don't have Digibind? Then what do you do in those situations?

Well, we just opened our free standing ED July 1 2009, so are in the growing phases. Didn't have any meds either for pediatric pneumonia (sans PO amoxil), things we didn't really think about when opening it. Its no big deal, really, we have MOST of the emergent things one would need (though I just found out we have no antiseizure meds sans benzos or propofol). I called the MICU at our "mothership" hospital and got them to get 2 vials of digibind ready, she was transported via EMS and got there. After 2 hours thankfully she never really rebounded, didn't need any further treatment besides the digibind.

That being said, I am always up for cool cases to discuss. I freely admit I have been lax on my SDN, working a bit more to save up for buying a house, which means less SDN time....

Q

 

[BADMD]

Yeah, we just opened our freestanding ED July 1st, so still going through some growing pains. I already emailed out the med director. Yeah no digibind. Ugh.

There was an article published in Annals this month with a recommended antidote list for hospitals. Some of them are touch ridiculous (Getting DTPA is not easy, for ex) but it can give you a guideline and some ammunition.