Codes in known hyperkalemia - best initial approach?

[MedicineZ0Z]

So you have a patient with known hyperkalemia in the admission, lets say it was running in the high 6s with some EKG changes and you have a good reason to think that's why he arrested.

You start ACLS and he has no central access or anything. What's the ideal timing and sequence of pushing meds? Immediately giving calcium gluconate (3g) with insulin/dextrose (5 and 25) followed by 100 bicarb? And re-dose calcium subsequently if no success while addressing other possible causes as acls continues?

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[Hernandez]

Realistically it it’s going to depend on what is in your code box and in what form.

The insulin is not likely in the Box and will have to be pulled. Calcium should be in the code box as well as dextrose and bicarbonate. We currently have a shortage on premade Bicarb syringes and have to pull it up which is a PIA. so in a real scenario it’s going to go calcium, dextrose, bicarb, then insulin. I’m not sure if there is much utility to squabble about bicarb or dextrose/insulin first. I would use calcium first however.

 

[MedicineZ0Z]

Realistically it it’s going to depend on what is in your code box and in what form.

The insulin is not likely in the Box and will have to be pulled. Calcium should be in the code box as well as dextrose and bicarbonate. We currently have a shortage on premade Bicarb syringes and have to pull it up which is a PIA. so in a real scenario it’s going to go calcium, dextrose, bicarb, then insulin. I’m not sure if there is much utility to squabble about bicarb or dextrose/insulin first. I would use calcium first however.

Makes sense. And when would you redose calcium? Especially in a known hyperkalemic arrest. And still going at 3g with the gluconate?

 

[MediMike]

Do you carry gluconate on your code cart/box? Prefills of CaCl are more common in my experience, but suppose every facility is different.

 

[vector2]

Makes sense. And when would you redose calcium? Especially in a known hyperkalemic arrest. And still going at 3g with the gluconate?

CaGluc doesn't really come in code boxes because it's typically sent from pharmacy in a 1g/50ml bag. The pt will be getting 1-2 g (10-20 ml) of calcium chloride PIV push (while we all pray there's not an extravasation injury).

 

[aafisahar]

Calcium calcium, calcium, calcium. If they make urine, please give them a real dose of diuretic like 200mg Lasix plus 1g diuril. You can give fluids back and you should, but in a hyperK code, this isn't the time to be conservative.

 

[ShockIndex]

I’d give CaCl in a code over CaGlu. It’s 3X the elemental Ca. After that, I’d give Epi and redose with CaCl. Sodium bicarbonate is often given but may be counterproductive when given as a bolus since the hypertonic solution solution causes solute drag, and due to the CO2 load in cardiac arrest. Insulin takes 10-20 min to work which is why I don’t give it in a cardiac arrest. I’ll consider insulin and isotonic bicarbonate infusion if they have ROSC.

Again, the Board answer is CaCl for the first line treatment in cardiac arrest.

 

[Lexdiamondz]

CaGluc doesn't really come in code boxes because it's typically sent from pharmacy in a 1g/50ml bag. The pt will be getting 1-2 g (10-20 ml) of calcium chloride PIV push (while we all pray there's not an extravasation injury).

In a code situation (assuming you have enough hands) couldn't you just place an IO or a femoral CVL?

 

[vector2]

In a code situation (assuming you have enough hands) couldn't you just place an IO or a femoral CVL?

If I walk up to a code, the pt has what appears to be a working IV that I've flushed myself, and I have a very high suspicion of hyperkalemic arrest, I'm not delaying treatment with CaCl to place alternative access.

 

[deleted547339]

Calcium calcium, calcium, calcium. If they make urine, please give them a real dose of diuretic like 200mg Lasix plus 1g diuril. You can give fluids back and you should, but in a hyperK code, this isn't the time to be conservative.

I was about to write “calcium calcium calcium calcium” but you beat me to it.

 

[ShockIndex]

In a code situation (assuming you have enough hands) couldn't you just place an IO or a femoral CVL?

People have been successfully giving CaCl via peripheral IVs for decades in ED and prehospital environments.

Don’t over think this. The priorities in cardiac arrest are 1) immediate access to continuous, high-quality CPR and 2) restoration of a perfusing rhythm. It is well known that procedures like central lines are a threat to #1 and #2 is best accomplished with lots of Ca when the cause of the arrest is known to be hyperK.

 

[alpinism]

The correct answer is immediate IV Calcium Chloride and Isotonic Sodium Bicarbonate.

 

[turkeyjerky]

I'll add to the chorus advocating immediate and aggressive calcium usage. I'll typically give 2 amps of calcium chloride along w/ the usual measures.

Not sure what insulin/dextrose adds to this. By the time it'll kick in, the patient'll either have rosc or be dead...

I do however like pushes of bicarb in a code situation (as opposed to the non-code situation, when it's vastly overused). I believe there's some evidence about the utility of hypertonic saline reversing the cardiotoxicity of severe hyperkalemia leading to 'membrane stabilization'. With a (future) dead body laying in front of you, I think it's reasonable to extrapolate this to hypertonic sodium bicarb (since we don't typically have hypertonic saline in a code cart).

 

[Hamhock]

I think it's reasonable to extrapolate this to hypertonic sodium bicarb (since we don't typically have hypertonic saline in a code cart).

I am not sure you want to be using 3% sodium chloride anyway; in an situation where acidemia is already likely present and acidemia worsens hyperkalemia. It has a pH of 5 or so.

HH

 

[Siggy]

As others have said, calcium calcium calcium. Chloride vs gluconate? Who cares, give what ever is in your cart. When to redose? Dose 3-5 minutes until your rhythm has narrowed or you stop the code.

I guess the other thing you can do if you have an extra RT and a ballard (Closed suction system... which you really just need the 90 degree turn for practical reasons) is 15-20 mg albuterol neb. If you're having someone go for insulin, you might as well neb them too. Just note, 15-20 mg albuterol... not the 3mg dose in a duoneb treatment.

 

[WheezyBaby]

Out of curiosity, what ballpark success rate do you guys have for ROSC in arrest secondary to presumed hyperkalemia? My initial assumption would be reasonable given a reversible etiology, but in practice I think it's been poor for adults, not that I have a terribly high sample size. I think the comorbidities (acute liver failure, ESLD, poorly cared for severely vasculopathic ESRD) of the patients ive seen have presumed hyperkalemic arrest just don't have great substrate for achieving ROSC

 

[MediMike]

Out of curiosity, what ballpark success rate do you guys have for ROSC in arrest secondary to presumed hyperkalemia? My initial assumption would be reasonable given a reversible etiology, but in practice I think it's been poor for adults, not that I have a terribly high sample size. I think the comorbidities (acute liver failure, ESLD, poorly cared for severely vasculopathic ESRD) of the patients ive seen have presumed hyperkalemic arrest just don't have great substrate for achieving ROSC

I'm running 66% for the last 4 months or so with an N=3. The last one had an unclear downtime, was brady as all get out to begin with, being "paced" by the ED without actual mechanical capture. Got ROSC several times but nothing sustained, ending up calling it in the resus bay. Unclear if it was primary or secondary hyperK. From the looks of the rhythm strips from EMS it may have been primary.

The other two were rapid responses from the floor, one guy who got overdiuresed into an AKI and they just kept squeezing, other AKI with no one paying attention to his lyte repletion.

 

[lymphocyte]

As others have said, calcium calcium calcium. Chloride vs gluconate? Who cares, give what ever is in your cart. When to redose? Dose 3-5 minutes until your rhythm has narrowed or you stop the code.

I guess the other thing you can do if you have an extra RT and a ballard (Closed suction system... which you really just need the 90 degree turn for practical reasons) is 15-20 mg albuterol neb. If you're having someone go for insulin, you might as well neb them too. Just note, 15-20 mg albuterol... not the 3mg dose in a duoneb treatment.

If you have access to it, I love IV albuterol/salbutamol. 200-500mcg IV loading followed by an infusion. Has served me very well three times now in peri-arrest situations when they got wonky rhythms (and I'm also slamming in calcium/getting ready for HD). Nebulisers are no bueno for us given COVID areorsol risk.

This was studied back in the good old days when you could do anything to anyone.

Potassium-Lowering Effect of Albuterol for Hyperkalemia in Renal Failure

• To study the effect of specific β2-adrenergic stimulation on potassium metabolism in renal failure, we intravenously administered albuterol (Salbutamol) sulfate, 0.5 mg, to 20 patients with chronic renal failure (glomerular filtration rate, <5 mL/min) receiving maintenance hemodialysis. Within...

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