There was a really cool course that I was an instructor for called ACLS-EP, Advanced Cardiac Life Support for Experienced Providers. It was like an ACLS on steroids and it was designed in four different segments, which meant you had a cardiac section, electrolytes section, environmental section and a tox section.
There were four different sections that you went through throughout the day and it was really cool. The electrolytes session was very insightful, but it wasn’t just insightful from a teaching standpoint. It aligned with what I did clinically, because as a hospitalist, every time I ran a code and it was a PEA arrest, I would ask for two things, at times giving me answers to why they coded.
Number one, I would say, “What medicines did this patient get within the last two hours?” The second thing I would say is, “Bring me the morning labs.” It was not uncommon for them to bring me a set of labs that showed a potassium of 6.4 and this was at 7:00 AM. It’s presently midnight and no one addressed the potassium. I would treat the hyperkalemia and we would save people. It was awesome.
The rhythm script that you’re looking at in front of you with hyperkalemia, you have to understand, there are three different signs of hyperkalemia, and it’s pretty cool. It follows a progression. Remember, if you take a PQRS&T wave and bend it out of a coat hanger, you put the two ends of the QS complex in a clamp, and you grab on to the T wave, and you slowly start pulling up, three things are going to happen. This is the progression of hyperkalemia.
Number one is the T waves become peaked. Second thing, the QS complex will widen out. The third thing that will happen, that P wave will flatten. That’s a progression. Peaked T waves, wide complex QSs and flat P waves. In the process of doing this, they become bradycardic. The rhythm that you’re looking at that can fool you to say, “Bradycardia. I have to treat this like a bradyarrhythmia.” Listen, listen, listen, if you treat this rhythm like a bradyarrhythmia, the patient dies. This hyperkalemic bradyarrhythmia has got to be treated for the hyperkalemia and the bradycardia will take care of itself.
Someone posed a question saying, “Wait, wait. What should do we? Atropine or pacing?” No, the answer is treat the hyperkalemia, and then treat the bradycardia. The thing is, ladies and gentlemen, once you treat the hyperkalemia, the heart rate is going to pick up. This is a huge landmine. Please listen. When it comes to resuscitation, electrolyte emergencies really all revolve around potassium. If you had 50 electrolyte emergencies, 49 of them are going to be hyperkalemia, and it’s all about dialysis patients or renal failure patients. Those are key.
If you have bradyarrhythmia, don’t get burned. Another way you can get burned about a bradyarrhythmia is someone has a heart rate of 42 chest pain, do you use nitro or atropine? That’s a question I’m going to put back on the table. Remember, treat the hyperkalemia. Think about renal failure patients.