EMS recently had a call for a critically ill dialysis, diabetic patient who went unresponsive at home.

66-year-old female found unresponsive at the kitchen table.

EMS arrives and finds her arousable the following vital signs:

100/80, 100p, 22 RR, 36C Following EKG

EMS felt this was V-tach and synchronized cardioverted.  Patients went into PEA arrest and standard cardiac arrest care was initiated.

The ED doctor recognized the initial EKG as sine wave and aggressively treated hyperkalemia.  Pt was emergently dialyzed in the ICU and survived.

Discussion:

1)      History is the foundation of your care.  This is a dialysis diabetic heart patient.  Knowing this should lean you into looking for peaked T-waves, but the more critical rhythm is sine wave just before they arrest.  Be aggressive.  If alert, run continuous Albuterol aerosol.  Initial membrane stabilization is done with IV calcium chloride 1gm IV or calcium gluconate, 1gm to 3gm IV.  Followed by sodium bicarb in a separate IV 1mEq/Kg IV.  The bicarb is reserved for the sine wave in the field.  The ED will give insulin, glucose and potassium binding meds as wee prepare the patient for emergency dialysis.

2)      Remember that V-tach is much faster than this wide rhythm, usually over well over 120 BPM, usually around 160 regular uniform and fast.

3)      Sine waves are wide and slow, with a history of renal failure it represents a pre-terminal event.

4)      PEA reminder to always go over your Hs and Ts, you might find a reversable cause, that can truly save a patient’s life.

Question 1

What is the most critical part of patient care?

A)     Vital signs.

B)     EKG

C)    Pox

D)    Capnography

E)     History

Answer: History is the foundation of everything that you will have to accomplish for your patient.

Question 2

What is the most critical drug to administer for severe sine wave hyperkalemia?

A)     Sodium Bicarb

B)     Calcium

C)    Albuterol

D)    IV fluids

Answer: It is the calcium that stabilizes the cellular cardiac membrane and gets the cells to contract.  The rest of your therapy including what the ED is doing, simply moves potassium intracellularly until emergent dialysis can be accomplished.

Thanks for reading, stay safe out there!  Don Spaner MD