[CK] Hyperkalemia preset. EKG

Hyperkalemic emergency − Patients who have clinical signs or symptoms of hyperkalemia (eg, muscle weakness or paralysis, cardiac conduction abnormalities, cardiac arrhythmias), patients with severe hyperkalemia (serum potassium >6.5 mEq/L), and patients with moderate hyperkalemia (serum potassium >5.5 mEq/L) plus significant renal impairment and ongoing tissue breakdown or potassium absorption) have a hyperkalemic emergency.

•Patients needing prompt therapy − Some patients with moderate hyperkalemia but without a hyperkalemic emergency should, nonetheless, have their potassium lowered promptly (ie, within 6 to 12 hours). Such patients include hemodialysis patients who present outside of regular dialysis hours, patients with marginal renal function and/or marginal urine output, or hyperkalemic patients who need to be optimized for surgery.

•Patients who can have the potassium lowered slowly − Most patients with hyperkalemia have chronic, mild (≤5.5 mEq/L) or moderate (5.5 to 6.5 mEq/L) elevations in serum potassium due to chronic kidney disease (CKD) or the use of medications that inhibit the renin-angiotensin-aldosterone system ([RAAS] or both). Such patients do not require urgent lowering of the serum potassium.

1. Peaked T waves best seen in the precordial leads, shortened QT interval and, at times, ST segment depression
   
   
   
2. Widening of the QRS complex (usually potassium level ≥ 6.5 mEq/L). This frequently appears as “non-specific intraventricular conduction delay,”characterized by a widened QRS complex of greater than 120 milliseconds that does not meet the criteria for a left or right bundle branch block. Frequently, an IVCD will look like a LBBB in lead V1 with a rS complex or monomorphic S wave, and it appears like a RBBB in leads I and V6 with a broad, slurred S wave.
   
   CLINICAL PEARL: If you see an IVCD, think of hyperkalemia.
3. Decreased amplitude of the P waves, an increase in the PR interval and bradycardia in the form of atrioventricular blocks occur as the potassium level exceeds 7.0 mEq/L
   
   CLINICAL PEARL: Supportive measurements like fluids, pacing and pressors do not work in the setting of hyperkalemia. You must treat the hyperkalemia first.
4. Absence of the P waves and eventually a “sine wave” pattern, as seen below, which is frequently a fatal rhythm 

SHORT QT, PEAK T, ST depression

Wide QRS(6.5)

Flat P(7)

Urgency >6.5
High >5.3

kayexalate 15g => decrease 0.8(60g: 1.4,, so 30g maybe 1.1 !) 
K level decreases ranging from 0.8 to 1.4 in those given 15g and 60g respectively

Ca gluconate 1000mg IVP(2mins)
D50 + RI 10units
Albuterol.can be given as 10 to 20 mg in 4 mL of saline by nebulization over 10 minutes


OR

lasix(diuretics)

calcium gluconate: 1000mg IV(2-3mins) with tele

                                  can be repeated after five minutes if the ECG changes persist or recur.

cf)Ca chloride= tissue necrosis, only via central

cf)Digitalis +hyperkalemia: needed to be treated with Ca gluconate(but slowly, why? hypercalcemia+digitalis also cardiotoxic) BUT TOC = digoxin-specific antibody fragments(preferred) ; a dilute solution can be administered slowly, infusing 10 mL of 10 percent calcium gluconate in 100 mL of 5 percent dextrose in water over 20 to 30 minutes, to avoid acute hypercalcemia.


<SHORT QT>

DIFFERENTIAL DIAGNOSIS: 

1. Normal variant — 2 percent of the population has QT intervals ≤360 milliseconds

2. Acquired causes of short QT interval — hyperkalemia, acidosis, hypercalcemia, hyperthermia, 

HIGH K, HIGH Ca(SAME DIRECTION of EKG but opposite from each other)

ACIDOSIS

MI 

KCAMI !!!(acidosis!!) = NOT GOOD 

Digoxin

3. Deceleration-dependent shortening of the QT interval 

Parasympathetic tone(high) 

Tx. may not be associated with an increased risk of sudden cardiac death (SCD). Because the rate of serious complications of implantable cardioverter-defibrillator (ICD) therapy is not trivial, particularly over the life of a young patient, it is important to discriminate between patients with an isolated short QT interval and those who meet the criteria for SQTS (table 2). Prior to making a final decision regarding the management of these patients, acquired causes of a shortened QT interval should be excluded. (See 'Acquired causes of short QT interval' above.)