38 yo AAM with 2 day h/o lightheadedness, weakness, presents to ER from dialysis hypoTN 79/49

PMH

• ESRD - HD (M-W-F)
• HTN
• Afib
• CHF

PSH

• Renal transplant x 2
• Nephrectomy 2/2 rejection
• Parathyroidectomy

Meds

• PhosLo - 4 pills qday
• Cardizem 360 SR qday
• Coreg 25 bid
• Enalapril 10 qday
• ASA 81 qday
• Nexium 40 qday

NKDA

FHx

• CVA

SocHx

• No tobacco, EtOH, or drugs

Vital Signs (13:20)

• Afebrile, P 63, BP 88/62, RR 18, Sa02 100%2L

Physical Exam

• NAD, AAO x 3
• PERRL
• CTAB/L
• RRR S1-S2
• Soft, NT, peritoneal catheter
• No edema
• Peripheral pulses intact

Differential for HypoTN?







Prior EKG (7 months ago)



Initial ED EKG (13:29)



BP drops further, pt lightheaded, repeat EKG (16:40)



Difficult IV access, delay in labs (sent @ 13:45) - K+ = 6.7
Repeat EKG after treatment (16:55), K+ = 5.4



Repeat EKG after inpatient admission







Early hyperkalemia:



Late hyperkalemia:








Most common causes for hyperkalemia?

1. Spurious - lab error or hemolysis
2. Renal Failure - acute versus chronic
3. Acidosis - DKA, Adrenal Insufficiency, Type 4 RTA, Addison's disease
4. Cell death - rhabdomyolysis, Tumor Lysis Syndrome, burns, crush injury, transfusion
5. Medications - BB, digitalis toxicity, succinylcholine, ACE-I, ARB, NSAIDs, sprinolactone, amiloride
   

Treatment for hyperkalemia?

• PIV Calcium Gluconate / CVC Calcium Chloride (3x the Ca2+) - caution in setting of Digitalis toxicity
  
• Insulin + Glucose (may need D50 x 2 amps if blood sugar is normal at therapy initiation)
  
• Albuterol Nebs
• Saline
  
• Kayexalate
• Sodium Bicarb
• Hemodialysis