What does Potassium do for you? Aids in the conversion of glucose into glycogen Assists in carbohydrate and protein metabolism 2018 Spring Fling EMS Conference Maintains balance between cells and body fluids Regulates muscle and nerve function Regulation of Muscle and Nerve Function -70mV Regulation of Muscle and Nerve Function +30mV 1
Regulation of Muscle and Nerve Function Regulation of Muscle and Nerve Function -70mV -70mV Regulation of Muscle and Nerve Function GET THE POINT? 2
Diuretics HYPOKALEMIA G.I. Loss Transmembrane Shift High aldosterone levels Dialysis Diuretics Thiazides (HCTZ) Elderly Can increase serum glucose levels Increases excretion in the late distal tubule Lasix (furosemide) HTN, CHF G.I. loss Vomiting Dehydration Alkalosis G.I. loss Laxative abuse Enema abuse Diarrhea 3
Transmembrane Shift Alkalosis Promotes K shift from plasma ICF Provokes kidneys to release K excessively into the urine Transmembrane Shift Insulin stimulates the Na/K pump = K into cells Transmembrane shift High catecholamine levels Albuterol Methamphetamine Cocaine OTC decongestants Ephedrine, pseudoephedrine Transmembrane shift Hypothermia Catecholamine response Increased serum aldosterone levels Stimulates Na uptake and K loss at the collecting duct Cushing Syndrome Cushing Syndrome Usually affecting middle-ages and women more than men Caused by an abnormally high circulating level of cortisol May be produced: Directly by an adrenal gland tumor By prolonged administration of corticosteroid drugs COPD, asthma By enlargement of both adrenal glands due to a anterior pituitary tumor 4
Cushing Syndrome Cushing Syndrome Signs and Symptoms Fatigue Confusion Restless leg syndrome Cramping, discomfort Muscle weakness paralysis Dysrhythmias Constipation How We Doin? QT (Prolonged) T wave = repolarization of ventricle myocardium U wave = repolarization of Purkinje fibers (V2, V3) QT interval = estimates the duration of an average ventricular action potential Prolonged QTIs can lead to arrhythmias 5
H Y P E R K A L E M I A Hyperkalemia Kidney failure Acute or chronic Shock Decreased aldosterone levels Addison s disease ACE inhibitors, NSAID s Burns / crush injuries Insulin deficiency Kidney Failure Shock Hyperkalemia Decreased aldosterone levels Addison s disease Addison s Disease Most common cause is autoimmune attack on the adrenal gland/cortex Adrenal steroid release is greatly reduced Mineralocorticoids (aldosterone) Major disturbances in water and electrolyte balance Increased sodium loss dehydration Potassium retention 6
ACE Inhibitors Examples Capoten (captopril), Vasotec (enalapril), Zestril (lisinopril) Hyperkalemia Burns / Crush Injuries Rhabdomyolysis Acidosis Muscle Overuse 7
Insulin deficiency Hyperkalemia Acidosis Shift of potassium from ICF plasma ECG Changes of Hyperkalemia Easily Distinguished ECG signs: peaked T wave prolongation of the P-R interval ST changes (which may mimic myocardial infarction) very wide QRS complex Patients may have severe hyperkalemia with minimal ECG changes, and prominent ECG changes with mild hyperkalemia Hyperkalemia 8
Hyperkalemia Clinical PEARLS Consider Hyperkalemia: Regular & really wide complex tachycardia Symptomatic bradycardia or heart block ECG shows STEMI but also something bizarre Altered/found down/hypotensive/peri-arrest Large T-waves make sure it s not hyperacute T s with acute coronary occlusion Prevent arrhythmias Shift potassium into the cells Excrete potassium from the body BIG K Drop B - beta agonists, bicarbonate I - insulin G - glucose K - kayexulate, calcium D - diuretics, dialysis Beta agonists Catecholamines increase activity of Na-K-ATPase pump 2-6,13,14 Levalbuterol and albuterol demonstrate equal ability to decrease potassium. 5-8 Potassium decreases by 0.6 mmol/l with 10 mg, and 1.0 mmol/l with 20 mg at one hour. 11, 15-17 terbutaline can be given IM in doses of 0.25 mg. 5-8,11,15-17 Combination treatment with insulin and glucose results in even greater decrease in potassium, 1.2-1.5 mmol/l at one hour after medication administration. 11,15-17 Sodium Bicarbonate When compared with other agents, bicarbonate does not result in significant decrease in potassium at 30 and 60 minutes. 7,8,12 Several controlled studies indicate sodium bicarbonate does not decrease potassium within 60 minutes. 5-8 Studies that do suggest a decrease utilized bicarbonate infused over hours and in patients with acidosis. 18,19 Common use = hyper-k cardiac arrest 50 meq, repeated prn Bottom Line: Sodium bicarbonate can be used in patients with acidosis and hyperkalemia, but is not useful in other patients. 9
Calcium Chloride Three times the amount of elemental calcium as the same mass of calcium gluconate Terrible peripheral extravasation consequences Hyper-K cardiac arrest management 10 ml IV with repeat dosing until QRS < 100 ms 9,10 Calcium Gluconate Does not require hepatic metabolism 1 No significant extravasation risk Hyperkalemia Clinical PEARLS Symptoms of hyperkalemia are usually nonspecific, so risk factors must be used to suspect the diagnosis ECG changes consistent with hyperkalemia should be treated immediately as a life-threatening emergency. IV calcium is the antidote of choice for life-threatening arrhythmias related to hyperkalemia, but its effect is brief and additional agents must be used. Thank You For Attending!! Christopher Ebright B.Ed., NRP EMS Education Coordinator National EMS Academy Covington, LA c.ebrightnremtp@gmail.com Christopherebright.com References References Evans KJ, Greenberg A. Hyperkalemia: a review. J Intensive Care Med. 2005 Sep-Oct;20(5):272-290. Kamel KS, Wei C. Controversial issues in the treatment of hyperkalaemia. Nephrol Dial Transplant. 2003;18:2215-2218. Sood MM, Sood AR, Richardson R. Emergency management and commonly encountered outpatient scenarios in patients with hyperkalemia. Mayo Clin Proc. 2007 Dec; 82(12):1553-1561. Hollander JC, Calvert CJ. Hyperkalemia. Am Fam Physician 2006; 73:283-90 1. Martin TJ, Kang Y, Robertson KM, et al. Ionization and hemodynamic effects of calcium chloride and calcium gluconate in the absence of hepatic function. Anesthesiology. 1990 Jul;73(1);62-5. 2. Faridi AB, Weisberg LS. Acid-base, electrolyte and metabolic abnormalities. In: Critical Care Medicine: Principles of Diagnosis and Management in Adults. Parrillo JE, Dellinger RP (Eds). Third Edition. Philadelphia, Elsevier, 2008;1203 1243. 3. Mount DB, Zandi-Nejad K. Disorders of potassium balance. In: Brenner and Rector s The Kidney, 9th Ed, WB Saunders & Company, Philadelphia 2011. p.640. 4. Brown RS. Potassium homeostasis and clinical implications. Am J Med.1984 Nov 5;77(5A):3-10. 5. Kidney International 2016;89:546 554. 6. Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008;36(12):3246-51. 7. Batterink J, Cessford TA, Taylor RAI. Pharmacological interventions for the acute management of hyperkalaemia in adults. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010344. DOI: 10.1002/14651858.CD010344.pub2. 8. Mahoney BA,Smith WA, Lo DS, et al. Emergency interventions for hyperkalaemia. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003235. 9. Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution. Resuscitation. 2010;81:1400 1433. 10. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S829 S861. 10
References 11. Allon M, Copkney C. Albuterol and insulin for treatment of hyperkalemia in hemodialysis patients. Kidney Int 1990;38(5):869-72. 12. Allon M, Shanklin N. Effect of bicarbonate administration on plasma potassium in dialysis patients: interactions with insulin and albuterol. Am J Kidney Dis 1996; 28: 508-14. 13. Clausen T, Everts ME. Regulation of the Na, K-pump in skeletal muscle. Kidney Int 1989; 35:1 13. 14. Moratinos J,Reverte M. Effects of catecholamines on plasma potassium: the role of alpha- and beta-adrenoceptors. Fundam Clin Pharmacol. 1993;7(3-4):143-53. 15. Allon M. Hyperkalemia in end-stage renal disease: mechanisms and management. J Am Soc Nephrol 1995; 6:1134. 16. Allon M, Dunlay R, Copkney C. Nebulized albuterol for acute hyperkalemia in patients on hemodialysis. Ann Intern Med. 1989;110:426-9. 17. Allon M, Shanklin N. Effect of albuterol treatment on subsequent dialytic potassium removal. Am J Kidney Dis 1995;26:607-13. 18. Fraley DS,Adler S. Correction of hyperkalemia by bicarbonate despite constant blood ph. Kidney Int. 1977 Nov;12(5):354-60. 19. Gutierrez R,Schlessinger F, Oster JR, et al. Effect of hypertonic versus isotonic sodium bicarbonate on plasma potassium concentration in patients with end-stage renal disease. Miner Electrolyte Metab. 1991;17(5):297-302. 11