Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1 39M DM1 (poorly controlled), HTN, EtOH...

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Shawn Dowling PGY-2 ECG Rounds ©Aric Storck

Transcript of Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1 39M DM1 (poorly controlled), HTN, EtOH...

Page 1: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Shawn Dowling

PGY-2

ECG Rounds ©Aric Storck

Page 2: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Case #1

39M DM1 (poorly controlled), HTN, EtOH abuse,

recurrent pancreatitis Presents w/++NV, developed epigastric/CP O/E – HR 130, BP 70/30, Fluid: Dry, anuric Cardiac exam - Normal

Page 3: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 4: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 5: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Pt got ‘lyticsK+ was 8.9, Cr was 252ECG did not change w/lytics, but with insulin/bicarb…

Page 6: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 7: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Case #2

87F Feeling weak and dizzy PMHx – heart failure, prior MI Meds - on some heart meds – you know the little

white ones… ECG…

Page 8: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

What do you think? How do you want to treat this patient?

Page 9: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

A few hours later the clinical clerk shows you her repeat ECG, and says “cool I’ve never seen an ECG like this…”

Do you want to change any of your meds for treating her high K?

Page 10: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Case #3

79M 2 hrs of RSCP (good story for ischemia) Cardiac RF: all of ‘em ECG…

Page 11: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 12: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

What does hyperacute ischemic T waves have to do w/high K?

Page 13: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Summary ECG findings

Peaked T-waves (>5mm)QT shorteningST elevation Increased PR/loss of P waveWidening/Slurring QRSSine wave appearance2nd/3rd degree block, VF, asystole

Mild

Moderate

Severe

Page 14: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Although the ECG findings may or may not correlate to lab findings, arrhythmias can occur @ any level of hyperkalemia

Page 15: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Ca Cl or Gluconate

10mL of 10% over

10 mins (Cl = 360mg, Gl=93mg)

O:0-5 mins D:1 hr

Insulin & (Glucose)

10-20u bolus (if c/s <14mmol give glucose)

O: 15 mins D: 4-6 hrs

Effect – 0.6-1.0

Ventolin Nebs 5-20 mg

IV 0.5mg

O: 15 mins D: 2-3 hrs

E: N 0.5-0.9/IV .8-1.5

Na Bicarbonate

One Amp (44mEq) O: 15 mins D: 2 hrs

4 studies – 0 but small studies (5-10 pts)

Lasix 10-80mg IV O: 1 hr D: 2-4 hrs

Dialysis 1 nephrology resident E: 1.2-1.5 mEq/hr

Kayexalate Pt nice=PO 20gm

Pt nasty=PR 50gm

PO onset 1-2hrs

PR onset 30 mins

Drug Dosage Onset/Duration

MembraneStabilizer*

Shift*

Excretion*

*Tx w/ at least modality From each

Page 16: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Case #

46M. C/O - Feeling unwell, muscle cramping and

intermittent parasthesias Admits to laxative abuse VSS ECG…

Page 17: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 18: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.
Page 19: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

ECG findings

small or absent T waves prominent U waves ST segment depression QT prolongation/Pseudo VF/Torsades

Page 20: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Tx* Mild (3-3.4mEq)

PO replacement Moderate (2.5-3.0 mEq)

Minimal Sx and N ECG – PO replacementSignificant Sx and/or ECG changes – IV

Severe (<2.5 mEq) IV KCl

*Check Magnesium – replace if low or borderline

Page 21: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

K deficit = desired K – meas K x .25 x wgt (kg)Only an approximation since most K is intracellularWant to replace 75% of K w/i 1st 24 hrs

Page 22: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

Oral K-Dur (20mmol/tab) KCl elixir(20mmol/15ml) K-Phos(4.4mmol/ml)

useful if hypophosphatemic K-Citrate (0.9mmol/ml)

useful in RTA

IV KCl (10/20/40mmol/100cc) 10-20mEq/h >20mEq/h requires central

line and cardiac monitor

S/E’s transient hyperkalemia burning at IV site

Thanks for the slide Aric

Page 23: Shawn Dowling PGY-2 ECG Rounds ©Aric Storck. Case #1  39M  DM1 (poorly controlled), HTN, EtOH abuse, recurrent pancreatitis  Presents w/++NV, developed.

References

Rosen’s eMedicine.com