Chief Complaint: Lethargy… January 25, 2012

Posted by Andy Jagoda, MD in: Cardiovascular, Gastrointestinal, Hematologic/Allergic/Endocrine Emergencies, Renal and Genitourinary Emergencies , trackback

EMS brings in a 64-year-old gentleman with a chief complaint of lethargy. On arrival, the patient is bradycardic at 40 beats per minute with a normal blood pressure. You ask the nurse to immediately move the man to the resuscitation bay, obtain intravenous access, draw a rainbow of labs, and obtain an ECG. The EMS report states that they found him at home alone, unable to ambulate without assistance. The patient tells you that he has missed dialysis for the past few sessions because he did not have the energy to make it to clinic. You obtain an ECG and immediately notice concerning abnormalities.

What’s Your Next Step?

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1. rita cohen - January 27, 2012

I believe that this patient has hyperkalemia . I woluld have urged an immediate hemodialysis ,
meanwhile the patient can receive –
PO kayexalate – immediate
INH ventolin -immediate
IV glucose + insulin -in 20 minutes
IV ca-gluconate-immediate
IV bicarbonate-if hemodialysis is prosponed for hrs
connect the patient to an external pacemaker, but still not applying it
diuretics are not going to help a patient on hemodialysis , that might not give urine at all

2. Angie Carrick - February 1, 2012

Hyperkalemia. Treatment is Calcium, Bicarbonate, Insulin, Glucose and Kayexalate.

3. P Rywak - February 1, 2012

Presumptive treatment for hyperkalemia
IV Calcium gluconate
IV D50 / Insulin
Albuterol neb, continuous
Arrange dialysis

4. D.Ali Tariq - February 1, 2012

This is acase of critical hyperkalemia so we need imediat action to decrease K ion and Ill start calicium gluconate ,albutero,Insuline and glucose,untill HD ready ,Isaid itis critical hyperkalemia because of lethergy and bradycardia .

5. Omar Farid - February 1, 2012

i think the bradycardia due to hyperkalemia ,so the immediatly give :
IV calcium gluconate.
IV D50/ insulin.
Albuterol neb.
IV sodium bicarbonate.
contanius ECG moniter.
send blood for blood gas and cbc, electro. ,ca,mg. phosphate ,
also looke for anothers causes of bradycardia.

6. Tiffany Heu - February 1, 2012

With the missed dialysis sessions, this pt has severe hyperkalemia. The pt needs to be put on the cardiac monitor and have emergent dialysis. In the meantime the pt can receive IV Calcium gluconate, IV D50, insulin, Sodium bicarb, and albuterol neb.

7. Robert Ryman - February 1, 2012

Severe hyperkalemia is suspected.
1. Ca gluconicum 2x 10ml 10% slow iv bolus
2. ventolin inhalation
3. 40ml 40% + 20IU insulin and check labs after 30min (may be repeated if needed)
4. meanwhile contacting nephrologist to organize for urgent hemodialysis
5. meanwhile preparation for hemodialysis catheter insertion

8. Bo - February 1, 2012


9. charles chitwood - February 1, 2012


Hey-any good reference supporting admission of a 44 yo female with PMH seizure, COPD, smoker, on levaquin for 3 days, GERD who follows up worse with RR 20, temp 102, pulse ox 87%?

PORT score and CRB-65 don’t point to admission but she clearly needed it. D/c’d home and died that night.

Autopsy: aspiration pneumonia.

I’ll reciprocate/owe you. Couldn’t find anything solid.

10. Jesse - February 1, 2012

I agree that hyperkalemia would have to be the first concern and is usually the best guess for abnl ekg+dialysis, but that would not be a very interesting case, so I will add hypermagnesemia. It also is seen in renal failure and could cause ekg abnormalities, brady, weakness, etc. of course there is also cardiac, medication OD, etc.

What’s Your Next Step?>
I guess technically the next step is to get the rest of the vitals, put pads on the pt, and interpret the ekg.

11. Rauvan Averick - February 1, 2012

Hi K. Needs lower K ->dialyze.

12. Ela - February 1, 2012

Hyperkalemia with severe changes in ECG…
1)insulin 5- 10UI + glucose 10% to prevent hypoglycemia
2)Ca gluconate 10% iv in case of loss of P-wave in ECG
3)albuterol 20 mg inh
4)Na polysterine can help take of K from GI tract
5)hemodialisys is neccessary

13. Asim - February 1, 2012

Treatment ; IV calcium chloride , insulin with dextrose,
Salbutamol neb , sodium bicarbonate IV , kyxalate po , frusimide

14. liza - February 1, 2012

next step to be done–>
ECG showed bradycardia- need to identify what type of bradycardia-> junctional/first/second/3rd degree/sine wave bradycardia
then, do bedside test of venous blood gas if more worried of hyperkalaemia-> basically to look for acidosis as well as potassium level ( my VBG have this results )
if its true severely hyperkalaemia, then treat the hyperkalaemia with IV calsium gluconate 10% 10ml stat followed by IV insulin 10unit and IV dextrose 50% 50ml. if patient tooo acidosis ( PH <6.8), then may give IV sodium bicarbonate 8.4% 50-100ml. at the same time, alert the dialysis unit and prepare for dialysis. to buy time before dialyse, may give nebulizer ventolin to reduce the potassium level.
if the VBG doesnot shows hyperkalaemia, then other causes of bradycardia need to sought out, including ACS, other electrolytes abnormality as well as drugs induced hyperkalaemia.

15. James Park - February 1, 2012

Hyperkalemia. Emergent dialysis. In the meantime obtain a reliable peripheral iv access, preferably large bore, calcium chloride, D50, insulin, sodium bicarbonate, continuous albuterol neb. Keep the crash cart in the room. – James Park

16. Jeremy - February 1, 2012

Going to go out on a limb…any chance of digoxin toxicity here? Of course, will still need HD, but digibind in the meantime. Treat the bradycardia with atropine, though would be nice to see ECG results first.

17. AlMalki - February 2, 2012

the presumptive diagnosis of hyper K may be confirmed by charecteristic ECG changes. if so:

1- full monitor + attach defib. pads to pt.
2- 10% CaCl 10 ml IV stat, repeat q10-15 min PRN.
3- NaHCO3 50 meq IV stat.
4- Arrange for immediate hemodialysis.

18. Adel Noman - February 2, 2012

we should look to the ECG and confirm the hyperkalemia ,we will put him in ICU under monitoring until preparing him for emergent dialysis,during this time in ICU , WE should start with Ca gluconate amp IV,and albuterol inhaler,and NAHCO3 amp IV, dextrose 50% with insulin.

19. Meg - February 2, 2012

Hyperkalaemia is most likely, confirm with ABG, and typical ECG changes.
10 % CaCl 10 ml (will also treat hypermagnesaemia)
Shift K with Soda bic 50 ml of 8,5 % over 5 min (if acidotic), then 50 ml 50 % Dextrose and 10 u short acting insulin (dont infuse in the same line as RIngers or calcium)
salbutamol nebs
Be careful about giving furosemide with patient in renal failure.

20. Edwin Garcia - February 2, 2012

Patient missed his HD, so high probability of hyperkalemia and acidosis.
First step is to stabilize the patient. He is bradycardic and lethargic, which is a sing of instability. Therefore, he must be placed in a transcutaneous pacemaker while we treat for hyperkalemia: start with calcium gluconate, then 1 amp bicarb, 10 units Insulin R IV + 1 Amp D25%, kayexelate 30ml PO.
Consult immediately for emergent hemodialysis and admit to ICU.

21. Omar - February 2, 2012

1.Hyperkalemia (although he was weak before missing dialysis)
2. Infectious etiology
3. Hypothyroidism
4. Rhabdomyolsis
Next step would be to interpret EKG. Vital signs.

22. Ron Koury - February 2, 2012

Calcium Chloride 2 amps from the code cart NOW.
THEN, the Bicarb, insulin, D50, Albuterol,… with
simultaneous calls to team to do urgent dialysis,…
and consider Kayexylate,… depending on how soon H.D.
can be set up. (While pushing the Calcium, confirm your
clinical suspicion of the HyperK with a bedside electrolyte panel.)

23. Eric Stanley - February 2, 2012

It’s the K…..
My man needs:
IV calcium gluconate vs chloride depending on your IV hospital policy,
Hit him with IV insulin with dextrose unless his fingerstick is really high,
kyxalate PO and Lasix IV are good but slow, albuterol neb may help some, sodium bicarbonate IV if things are getting ugly, but this dude really need dialysis.

24. moonis - February 2, 2012

treat him for hyperkalemia

25. Anthony - February 2, 2012

It would appear that the patient may be hyperkaleamic, however other possibilites for his presentation should be ascertained. He seems to be tolerating the bradycardia despite his lethargy which is a sign of his hyperK state.

Not all patients will need every single medication thrown at them, but treatment needs to be initiated prompty whilst waiting for dialysis to be organised. We need to establish IV access, bloods drawn for analysis including ABG and continuous cardiac monitoring with preparation for deterioration.

Treatment should be aimed at stabilising the myocardium, moving K+ to the intracellular environment and both renal and GIT excretion of K+. Calcium and insulin can be administered with dextrose 50% and bicarbonate used if required. Essentially he requires immediate dialysis. Kayexalate probably should be avoided as there is some evidence suggesting it is of limited or no benefit and it can increase the chance of colonic necrosis (although rare).

We shouldn’t become tunnel visioned and investigate all possibilities for his presentation, but based on the history, hyperK would be number one on the list.


26. Rizwan Aziz - February 2, 2012

I think its a late stage of Hyperkalaemia with bradycardia which needs to be treated urgently

1) Attach pt to monitor & place transcutaneuos electrodes for probable need of pacing
2) Inform Neurologist for urgent dialysis
3) The goal standard is haemodylasis but to buy time we should go for the medical treatment
IV Calcium Gluconate 10 % 10 ml
IV Glucose water 50 % 40 ml + IV Regular Insulin 10 U
Calcium resonium PO
As this patient missed his dialysis he should be in fluid overload
Access & think of GTN infusion 10 MCG/min titrate according to systolic blood pressure


27. Sarah Melendez - February 3, 2012

Hyperkalemia and probably extreme by that point. Sure we’re already seeing widening of the QRS and close
To sine waves. Immediately ca glauconate and page renal. In the meantime I would give him an albuterol neb, 10 units insulin and D50 maybe even bicarbonate at this point because of how extreme this is. External pacers on in case. The only curative at this
Point is HD

28. Peter A. - February 6, 2012

Hyperkalemia is on top of the list, however, the man is a cardiopath by definition, so pads on and full cardiac work up is indicated. I would probably consider a CT head as well once hyperkalemia treatment has been given (B.I.G.K. – Bicarb, Insulin, D50, Kayexelate + CaGluconate+Albuterol inh), nephro consult and emergent dialysis.

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