As opposed to completely rehashing the previous post, here is the link if you need to read it: Sick dude.
It was fairly obvious to me, as well as to most of you I am sure, what this gentleman’s problem was from the outset. He was lots of things, but most notably, hypotensive, bradycardic, hyperkalemic, and hypoglycemic. Without having a serum K+, and just by looking at his ECG, I guessed a K+ around 7.
What I found to be interesting was the lack of the pacemaker firing, even though the LP15 sensed something on all the ECGs.
Frankly, I think the LP15 is making it up, because I don’t see a darned thing where it says there should be pacer spikes. When you get over my masterful skills in cutting and pasting, if you happen to see any spikes, please point them out.
But, his heart rate is 50, why isn’t the pacemaker working? Shouldn’t the pacer be set at a rate of 70 or so?
Why is he so hyperkalemic? He doesn’t look that sick to be this sick.
There are a bunch of things going on in my head here, while everyone else is devising a plan to move this guy to our stretcher. I know what my treatment for him is going to be, but I want to know why he is this sick to start with. Let me give you a more detailed list of meds:
- Ranitidine 150mg b.i.d.
- Doxazosin 4mg b.i.d.
- Norvasc 5mg q.d.
- Atenolol 50mg b.i.d.
- Lasix 40mg q.d.
- Warfarin 0.5mg q.d.
- Neurontin 600mg q.d.
- Potassium chloride 20 mEq packet q.d.
- ASA 325mg am
- Lisinopril 40mg q.d.
- Lipitor 40mg q.d.
- Plavix 75mg q.d.
- Metolazone 2.5mg q.d.
- Nitroglycerin 0.4mg tablet PRN
- Metformin 850mg b.i.d.
Lisinopril is an ACE inhibitor, and potassium is, well, potassium. Common risk factors for hyperkalemia are renal insufficiency, potassium supplementation, ACE inhibitor usage, and excessive consumption of a potassium diet. I didn’t enquire into the patient’s diet for the past few days, though admittedly I probably should have.
I was pretty confident we were dealing with hyperkalemia.
So we have a pretty good idea why he is hypotensive (vomiting and diarrhea) and hypoglycemic (vomiting, diarrhea, and lack of food intake), but why isn’t the pacer working?
From “Hyperkalemia induced failure of atrial and ventricular pacemaker capture” Int J Cardiol 2005 Nov 2;105(2):224-6.;
“a mild to moderate increase in serum potassium causes an increase in myocardial excitability, but further increase leads to impaired myocardial responsiveness, including that to pacing stimulation. Hyperkalemia has been reported to cause failure of atrial capture due to pacemaker exit block.”
Fair enough. So we have a fairly good idea why the pacer isn’t working. The gentleman became nauseous and experienced diarrhea, causing his hypoglycemia and hypotension, which led to renal insufficiency, which led to increased potassium retention and decreased urine output, which led to hyperkalemia, which led to his pacemaker failure, which led to his bradycardic rhythm, which led to him feeling like crap, which led to the 911 call, which led to me being in his house, which led to the case, which led to the blog. And on and on and on.
What I did for this gentleman was administer a large fluid bolus, almost 2 liters, of Dextrose 5%. Having a fairly good idea what was wrong with this gentleman, I decided that immediate transport to the closest hospital, as opposed to his preference, which was a good 45 minutes away, was in order.
I returned to Local Hospital several hours later, and discussed the case with the nurse who was taking care of the patient. She gave me the lab report, the most pertinent of which are below:
- RBC 3.95
- WBC 16.7
- K+ 7.7
- Lactic acid 11.2
- Hemoglobin 12.2
- Hematocrit 37
- Na 118
- Creatinine 16.4
- BUN >150
Most notably, this guy’s kidneys ain’t working.
Nurselady informed me the doctor had ordered calcium, bicarb, glucose and insulin. He was not given kayexalate due to his diarrhea. I didn’t ask about the doses of each. He was given a Foley, and 4 more liters of fluid through his IV.
In two hours, he had a urine output less than 50 milliliters.
Renal failure for sure.
I’ve always known the most important thing we can do for our patients is to get them to a hospital. But knowing why they are as sick as they are is also important to me, and I imagine to a large portion of EMS in general.
I will do some more awesome cutting and pasting with the 12-leads for the next post.