Hyperkalaemia

I:       You are the HDU registrar called to assist the HDU resident 

S:      He/she is concerned about new admission, a 66-year-old man with ESRF who has just undergone a fistula revision, 1 PVC and radial arterial line in situ 

B:      ESRF secondary to diabetes, recent cellulitis and fistula fail, usually on ACEi 

A:     Drowsy, responds to pain 

R:      Called you for assistance 

• Initially A gurgling, B RR 32, SpO2 89% on RA, coarse crackles bilaterally, C HR 100, BP 95/40, CRT 5 sec, D responds to pain, E fistula has a weak thrill 
• Abnormal ECG consistent with hyperkalaemia 
• Patient collapses into pulseless VT 
• Progresses down ALS algorithm 
• Continues until relevant reversible causes considered 
• Blood gas if requested - K+ 7.4 (venous or arterial) 
• ECG from admission to unit consistent with hyperkalaemia, consider calcium chloride 
• VT reverts to SR after defibrillation 
• Inadequate respiratory effort 
• Declares need for intubation and ventilation 

• Initial Settings (only visible once monitor attached): 
  • RR 32 
  • O2 Sats 89% on air 
  • Coarse crackles bilaterally to lung fields 
  • HR 100bpm – tall tented T waves on monitor 
  • BP 95/54 

• Progress to pulseless VT 

• Successful DC cardioversion only after administration of calcium chloride 

• Post DC Cardioversion: 
  • No respiratory effort
  • O₂ Sats 85% on 100% via BVM 
  • BP 145/88 
  • HR 118bpm SR 
  • Coarse crackles throughout lung fields 

Bedside Nurse: 

• You are a CNS 
• You have just received the patient from theatre recovery with little handover, except the preadmission letter and anaesthetic chart 
• You haven’t yet had time to attach the monitor – you are setting up a Hudson mask and oxygen tubing as routine 
• Do not attach any monitoring unless asked to do so – instead task yourself with documentation/looking for other equipment 

HDU Resident: 

• You have just started you HDU term 
• You know that the patient is 66 years old, has had an operation on a fistula, and is normally on dialysis – you note he is a “little drowsy” but you’re sure that it’s probably an effect of the anaesthetic as he has been to theatre 
• You take direction very well, but offer little 

HiLLO: 5, 7