Case summary:

An ALS crew responded to a 60s man with a history of diabetes who was confused.  Patient was found to be alert and oriented, but was breathing rapidly and deeply.  The crew noted her had absent radial pulses and had the following vitals:

Vitals: BP 106/58,  HR 115  RR 30,  Sat 96%, glucose hi

The crew places an IV and starts a fluid bolus.  The crew obtains the following EKG:

 The crew was concerned about the appearance of the EKG so they contacted online medical control to discuss.  The physician reviewed the EKG and was concerned for hyperkalemia.  The physician ordered 1 gram Calcium Chloride IV and rapid transport.  While in route the crew was able to obtain a second IV and gave additional fluids as well as gave 2 albuterol treatments to further treat hyperkalemia. 

Highlights of the case:

Hyperkalemia

The EKG that this crew obtained showed classic signs of severe hyperkalemia.  This patient had the classic peaked T waves that are often seen in hyperkalemia; however, these in themselves are not the most concerning signs that are present.  This patient also has prolonged intervals such as a prolonged PR and prolonged QRS.  While the peaked T waves are a concern, the prolonged intervals are a sign of severe hyperkalemia and impending cardiac arrest.  You will also notice that the EKG has a sine wave appearance.  It is easier to appreciate this on the rhythm strip that was also included.  The sine wave occurs when the intervals get so long that the whole QRS and T wave starts to fuse together.  The key when you suspect hyperkalemia is to be aggressive with treating it.  The most important treatment is giving IV calcium.  The reason for this is that it stabilizes the myocardium so that the elevated potassium in the blood will not affect it as much.  This will do 2 things.  First, it will decrease the likelihood of a fatal arrythmia.  Second, the EKG changes seen with hyperkalemia will immediately improve confirming that you are dealing with hyperkalemia.  Calcium does not do anything for potassium that is in the blood.  Potassium that is in the blood is what is toxic to the heart.  If we can get it into cells and out of the blood, it is not toxic.  There are two things that EMS crews regularly have that can be used to shift potassium out of the blood and into cells, albuterol and sodium bicarbonate.  Both can be given after calcium to further treat suspected hyperkalemia.  This crew obtained an EKG that was consistent with hyperkalemia and correctly got calcium on board quickly.  They then gave albuterol to treat hyperkalemia further.

Diabetic ketoacidosis (DKA)

This patient was almost certainly having hyperkalemia in the setting of DKA.  DKA occurs when a patient who is dependent on insulin does not receive any insulin for some reason.  This can be due to the patient not being good about taking their insulin, due to running out of their insulin, or due to some medical emergency affecting their ability to safely take their insulin.  A common scenario is where a patient develops nausea and vomiting that prevents them from eating.  Patients will then hold their insulin to prevent hypoglycemia in the setting of not having eaten anything.  While these patients are trying to prevent hypoglycemia, they still need some insulin to prevent DKA.  Due to the buildup of ketoacids, patients will compensate by breathing rapidly and deeply to try and blow off as much CO2 as possible to compensate.  This compensatory respiratory alkalosis is called Kussmaul breathing.  These patients are also typically very dehydrated.  The average patient with DKA is often >4-6L down.  This occurs due to all the urination that occurs in the setting of hyperglycemia since the body uses urination as a way of try to self-treat the hyperglycemia.  That is likely why this patient was tachycardic and had no radial pulse.  We want to initiate fluid resuscitation in patients with suspect DKA or other hyperglycemic emergencies, which is exactly what this crew did.   Another thing that occurs in DKA secondary to all the acid in the blood is that patients develop hyperkalemia, which is what was happening to this patient.