A 52-year old
homeless man on chronic dialysis with a history of non-compliance presents with
chest pain. CXR and EKG show the following. The next step should be:
B. Emergency pericardiocentesis and initiate heparin-free daily hemodialysis
C. Anticoagulate the patient immediately with heparin
D. Administer colchicine
____________
The correct answer for the dialysis quiz of September 25, 2011 is D. IV bicarbonate 8.4%, 1 to 2 amps IV.
The key words in this question are: "Recommended initial". While sodium bicarbonate administration will increase translocation of potassium from the extracellular to intracellular compartment, it doesn't happen immediately (see Fig. 1 and 2, below). The electrocardiographic (ECG) changes -- the tented T waves, the flattened P, and the prolonged QRS are typical of hyperkalemia. This patient has a dangerously high K because of the ECG changes.
The key words in this question are: "Recommended initial". While sodium bicarbonate administration will increase translocation of potassium from the extracellular to intracellular compartment, it doesn't happen immediately (see Fig. 1 and 2, below). The electrocardiographic (ECG) changes -- the tented T waves, the flattened P, and the prolonged QRS are typical of hyperkalemia. This patient has a dangerously high K because of the ECG changes.
A 48 year old male ESRD patient presents to the ED with a K=7.8 mEq/L, HC03 of 22. His EKG shows peaked T waves (see pic). Recommended initial treatment include all of the following EXCEPT:
–A.) Calcium gluconate 10 mls, IV
–B.) Insulin 10 units and 1 amp of 50% dextrose
–C.) Albuterol nebulizer (10-20 mg)
–D.) IV bicarbonate 8.4%, 1 to 2 amps IV
–E.) Emergent dialysis
Explanation
Explanation
The paper reporting delayed effect of sodium bicarbonate in hyperkalemia, as compared to other interventions, was published by Alfred Blumberg and colleagues in the Am J of Medicine. They reported that insulin and dextrose worked best in terms of speed in reducing the potassium level.
 |
| Figure 1 |
 |
| Figure 2 |
