Textbook Case

[docB]

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I had an 80 yo F BIBA from assisted living yesterday with a CC of weak and dizzy. Her initial EKG showed a wide complex bradycardia at 48. The Ts were kind of peaked and with the wide complexes and the weakness I suspected hyperkalemia. No Hx of renal problems. So here?s my problem, it?s 1 hour until I can get my Chem panel (my hospital and certain third world countries are the only places left without bedside lab capabilities) and if I treat it and I?m wrong I could do more harm than good. So I decided to put the pt on a cont neb of albuterol for an hour and give her 10u of subcu insulin (glu was 230) to try and temporize until my lab came back. It worked great. Ts came down, rate up to 80, QRS narrowed, pt got better. I repeated her EKG which showed the improvements about the time her K of 9.2 came back. After that hit her with the whole deal, Kayexelate, Ca, bicarb, glu, more insulin and admit to ICU with Nephro on the way. It was really cool to see a textbook type case where everything worked exactly like it is supposed to.

 

[cooldreams]

what is the norm for such "textbook" instances? sounds somewhat rare?

 

[mikecwru]

I had an 80 yo F BIBA from assisted living yesterday with a CC of weak and dizzy. Her initial EKG showed a wide complex bradycardia at 48. The Ts were kind of peaked and with the wide complexes and the weakness I suspected hyperkalemia. No Hx of renal problems. So here?s my problem, it?s 1 hour until I can get my Chem panel (my hospital and certain third world countries are the only places left without bedside lab capabilities) and if I treat it and I?m wrong I could do more harm than good. So I decided to put the pt on a cont neb of albuterol for an hour and give her 10u of subcu insulin (glu was 230) to try and temporize until my lab came back. It worked great. Ts came down, rate up to 80, QRS narrowed, pt got better. I repeated her EKG which showed the improvements about the time her K of 9.2 came back. After that hit her with the whole deal, Kayexelate, Ca, bicarb, glu, more insulin and admit to ICU with Nephro on the way. It was really cool to see a textbook type case where everything worked exactly like it is supposed to.

Why did you wait to hit her with Ca is you were treating her presumptively with a strong suspicion? I would have given her the Ca if I were giving her albuterol + insulin. The only griping point would have been if she were on digoxin.

Also, how about a blood gas with electrolytes to see the K faster than the chem panel?

Anyway, good job. Was she a new case of renal failure?

mike

 

[docB]

Why did you wait to hit her with Ca is you were treating her presumptively with a strong suspicion? I would have given her the Ca if I were giving her albuterol + insulin. The only griping point would have been if she were on digoxin.

Also, how about a blood gas with electrolytes to see the K faster than the chem panel?

Anyway, good job. Was she a new case of renal failure?

mike

Yeah, nephro thought she was dehydration leading to acute ATN with a new Cr of 3.5. I was +/- calcium at the early point because she was such a bad historian and didn't know if she was on Dig or not. She turned out to not be on Dig and her Ca was midrange so she got it once the labs were back. We don't have ABG with lytes. I had it when I was a resident and got used to it but now it's chem panel or nothing.

 

[Sessamoid]

Why did you wait to hit her with Ca is you were treating her presumptively with a strong suspicion? I would have given her the Ca if I were giving her albuterol + insulin. The only griping point would have been if she were on digoxin.

Also, how about a blood gas with electrolytes to see the K faster than the chem panel?

Anyway, good job. Was she a new case of renal failure?

mike

One thing you learn after residency is that not every hospital has the same resources. Myself, I've never worked at a hospital that had ABGs with lytes.

 

[docB]

You know, this is kind of turning into a discussion of bedside and point of care testing which is cool. I very much wish I had ABG with lytes and hemoglobin like I did in residency. There are also bedside troponin machines and plenty of other bedside tests. All I have now is GUIAC and finger sticks. Don't laugh, I have worked at a hospital where GUIAC cards had to be sent to the lab. Oops, code, gotta go. Shouldn't do SDN at work.

 

[roja]

We have stat K's on ABG's but we always have to call and FORCE the lab to do it. Aka- stay on the phone while they run it...


Good job.

 

[Sessamoid]

You know, this is kind of turning into a discussion of bedside and point of care testing which is cool. I very much wish I had ABG with lytes and hemoglobin like I did in residency. There are also bedside troponin machines and plenty of other bedside tests. All I have now is GUIAC and finger sticks. Don't laugh, I have worked at a hospital where GUIAC cards had to be sent to the lab. Oops, code, gotta go. Shouldn't do SDN at work.

We have to stea^H^H^H^Hre-locate the guaiac cards ourselves from our lab to keep them in the ED.

 

[docB]

We have to stea^H^H^H^Hre-locate the guaiac cards ourselves from our lab to keep them in the ED.

For us it's the developer. I would keep a bottle in my pocket but JACHO says I can't. Ya gotta love JACHO, they've turned poop testing into a covert operation.