Just Plain Ruff Posted July 17, 2007 Author Posted July 17, 2007 Bingo!! Sodium bicarb/CaCl/Albuterol ASAP. Do we have any electrical activity on the monitor, or is it still asystole? Might consider emergent dialysis, if it's available. Blasted phenothiazines anyway. well I thought you were on the right track. Patient was not given any phenothiazine. More information coming The physician ordered 40 meq's of KCL to be given to the patient via IV. Does this help?
AZCEP Posted July 17, 2007 Posted July 17, 2007 Just something to keep in mind. Phenergan can cause a retention of potassium which would elevate the level artificially, leading to some pretty significant problems. Adding some potassium to the IV might have been a good idea, but was it done in a way that was going to be easy to control? By that I mean, did they hang it in a separate bag that was not being used for fluid resuscitation, or was it just mixed in the one bag? Obviously we want to stop the infusion of the potassium for now, and try to normalize/stablize the situation. Was emergent dialysis available?
Just Plain Ruff Posted July 17, 2007 Author Posted July 17, 2007 Just something to keep in mind. Phenergan can cause a retention of potassium which would elevate the level artificially, leading to some pretty significant problems. Adding some potassium to the IV might have been a good idea, but was it done in a way that was going to be easy to control? By that I mean, did they hang it in a separate bag that was not being used for fluid resuscitation, or was it just mixed in the one bag? Obviously we want to stop the infusion of the potassium for now, and try to normalize/stablize the situation. Was emergent dialysis available? Nope, this was a hospital that had the nurses mix the bag of KCL so the order was 40meq of kcl. As you look over at the nurse who was taking care of the patient she has a very scared look in her eyes. Like something she had done might have contributed to this patients very very rapid arrest state. There is an empty vial of kcl (40 meq) and no label on the iv bag that is running. What question might you want to ask this nurse? She was indeed in the room with the patient when he arrested.
Just Plain Ruff Posted July 17, 2007 Author Posted July 17, 2007 One more item which will seal this scenario is that the nurse told you and the doctor that when she was administering the potassium that the patient complained that his arm really really burned. About the time he stopped talking is when she realized that the patient had gone into arrest.
AZCEP Posted July 17, 2007 Posted July 17, 2007 Rapid IV push KCl then? Did she put the potassium into the bag, or into the injection port? Where in blue blazes is the dialysis team? Let's take a moment to think about the scenario so far. A dehydrated middle aged male that is nauseated. IV running and sent to radiology to take a picture of the abdomen. Patient arrests following a mistake from someone and the patient's potassium is now off the charts. So there is evidence of some lactic acid building up, probably due to the dehydration leading to nausea. This will elevate the potassium level by itself, although it is not a true elevation. More of a misappropriation of the amount that is present. The dextrose containing IV solution is not going to help with the potassium level, or the fluid imbalance. Switching to a volume expander will be much more useful. This patient probably had some compromise of his renal function to start, we don't have IV fluids to maintain them as is, and then we add in the contrast dye. Any one of these things could have influenced the direction this is going, but in combination, obviously less than beneficial. The NaHCO3/CaCl/Albuterol/Insulin (I forgot that one before ) will temporize the problem, but we desperately need to get the offending electrolyte out of the system.
Just Plain Ruff Posted July 17, 2007 Author Posted July 17, 2007 small town hopsital - dialysis is about 100 miles to the north in KC MO. IV push potassium - 40cc's of potassium to be exact. Nurse was new, she didn't know to dilute the potassium in a bag of fluid. patient suffered massive cardiac effects and coded on the cot. never brought this patient back. Too much pottassium. this occurred about 10 or so years ago. This was before the IV"s with potassium were either pre- mixed or were mixed by pharmacists. It was also prior to the drug companies putting on the metal ring around the needle port "MUST BE DILUTED". According to my friend who told me about this, this was a very bad deal for all around.
ERDoc Posted July 18, 2007 Posted July 18, 2007 Wow, that sucks. To treat hyperK, the best options are calcium chloride (first and foremost as this will stabilize the caridac issues), if you can push only one drug this is what you want. After that, 10 units of insulin IV which will help push the K intracellularly (don't forget to give an amp of d50 so that we don't make him hypoglycemic). Bicarb also helps push the K into the intracellular space. Albuterol is also an option, but not pracitical in this situation from the sounds of it. In an emergency, dialysis it the last line of defense. Your pt will not make it to dialysis if you have not already started to take care of the problem and it may not be indicated if you can correct it with meds.
Just Plain Ruff Posted July 18, 2007 Author Posted July 18, 2007 neither did any of the responding crew members. It was only after the fact that it came out in the open. Bad deal
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