A 50 years old female patient who was on losartan and spironolactone therapy for her hypertension developed hypotension and bradycardia. The ECG taken is as below. Effective treatment for her
Temporary facing by right femoral vein
Intravenous nor adrenaline/phenylephrine
IV calcium gluconate followed by IV sodium bicarbonate
300J DC shock
Answer: c) IV calcium gluconate followed by IV sodium bicarbonateHYPERKALEMIAPlasma K+ concentration > 5.5 mmol/LPseudohyperkalemiaCellular efflux: thrombocytosis, erythrocytosis, leukocytosis, in vitro hemolysisHereditary defects in red cell membrane transport* Renal failure* | distal flow (| effective circulating volume)* Tubular secretory failure (| K+ secretion) * Impaired Na reabsorption(1deg,2degand pseudohypoaldosteronism)* |chloride reabsorption(Gordon's yndrome, cyclosporine)Drugs* ACE inhibitors* Amiloride* Cytotoxic drugs* Digitalis overdose* Heparin* Lithium* NSAIDs* Pentamidine* Spironolactone* Succinyl choline* TriamtereneEarly ECG changes of hyperkalemia (Serum potassium level 5.5-6.5 mEq/L)Tall, peaked T waves with a narrow base, best seen in precordial leadsShortened QT intervalST-segment depressionSerum potassium level of 6.5-8.0 mEq/LPeaked T wavesProlonged PR intervalDecreased or disappearing P waveWidening of the QRSAmplified R waveSerum potassium level higher than 8.0 mEq/LAbsence of P waveProgressive QRS wideningIntraventricular/fascicular/bundle branch blocksThe progressively widened QRS eventually merges with the T wave, forming a sine wave pattern. Ventricular fibrillation or asystole follows.Treatment of Hyperkalemia: indicated if the plasma K+concentration exceeds 6.5 mmol/l.Immediate antagonism of the cardiac effects of hyperkalemia (Stabilize cell membrane potential)I.V. calcium gluconateRapid reduction in plasma K+ concentration by redistribution into cells.* Inhale b2 agonist (salbutamol)* I.V. glucose (50ml of 50% solution) and insulin (5U Actrapid)Shift K+ into cells but no role in acute hyperkalemiaI.V. sodium bicarbonateRemove K+ from body* I.V. furosemide and NS* Cation-exchange resins (sodium polystyrene sulfonate-SPS) orally or rectally* Hemodialysis - most effective and reliable method
C.V.S.