Let this NP teach you about CHF

[gracie369]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

You can't be serious?!

I've got a kid crashing in here! Someone get me a MMR vaccine now!

"NPs on Call" would be a hit TV show.

---

Members don't see this ad.

 

[Jabbed]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

Ironic as it's not even in the initial protocol; you have to go out of your way for that sort of stupidity.

You have mid-levels running codes?

 

[Janders]

Actually, NPs in the ED would make them fit right in. Order a bunch of tests shotgun approach, have no idea what is going on, and send the patient home shruging their shoulders. Or see a little red number in a lab value, and call for an admission. Screw clinical judgment, or chronic diseases, red means blood!!

 

[calvnandhobbs68]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

Hurry, we need him to **** all over himself NOW!

 

[tiedyeddog]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

Rofl, just jam it in their mouth hole between rescue breathes. The bag mask will propel it down the mouth tube into the stomach food holder.

 

[Modafinil]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

kayexalate IV push

 

[alpinism]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

"Insulin!? They don't have diabetes!"

 

[cbrons]

"Insulin!? They don't have diabetes!"

LOL

 

[moonwake]

eat my image I found- does anyone really put PAs below nursing?

 

[cbrons]

My favorite was a midlevel yelling for STAT kayexalate during a code due presumably to hyperkalemia.

now come on, please tell me you made this up. This cannot be true.........

Now someone please educate me. Is calcium IV not the first line treatment for non-digoxin hyperkalemia associated with acute ekg changes + insulin/D50%w?

 

[calvnandhobbs68]

lol wtf is a "silent doctor"?

 

[Psai]

eat my image I found- does anyone really put PAs below nursing?
View attachment 191018

Dean of the hospital? Wat? Was this made by a third grader

 

[Shjanzey]

lol wtf is a "silent doctor"?

Perhaps this?

 

[WingedOx]

Could be there are simply terms that are zero tolerance. Agreed though, he backed down, apologized, and seemed to take it as a learning opportunity.

He's also said a lot of other really really dumb things.

I'm sure if he were here he would tell us his banishment was because of Democrats and the wussification of America or something...

 

[WingedOx]

No... MDs/DOs only. In fact, at one of our clinical sites the psych CL attending left and there was only an NP there to see the consults. They didn't have students go there because there was no physician to teach. Now I've certainly had rotations where you spend a good amount of time with an NP/PA, but in those situations you ultimately present patients to an attending and still get evaluated by an attending.

That's pretty weak if your supervisor is an NP/PA and you're actually getting graded by them.

Curious, but which hospital was this?

 

[Awesome Sauceome]

"Do you feel a doctor has more training than you?"

"It's different."

Lol. Ok.

whewwww sassy lassy

 

[jw3600]

Well if you listen carefully, she says her education is:
diploma (RN?), psych NP, bachelor's, family NP, master's, DNP.

I didn't even know you could get a NP before a bachelor's...

I like how she thinks it matter that she has 3 or 4 different NP degrees. That's like saying you took an EMT certification course THREE times. So obviously you have a bunch of education. This isn't even getting into the fact that the theory of nursing course you took twice a week does not help your diagnostic or clinical acumen.

 

[NickNaylor]

Curious, but which hospital was this?

Community hospital that we're affiliated with. If you'd like the specific one, I can PM it to you.

 

[tiedyeddog]

I like how she thinks it matter that she has 3 or 4 different NP degrees. That's like saying you took an EMT certification course THREE times. So obviously you have a bunch of education. This isn't even getting into the fact that the theory of nursing course you took twice a week does not help your diagnostic or clinical acumen.

Look, I took PALS, ATLS, BLS, and ACLS four times each this year. I am now a trauma surgeon. Why don't the people at my hospital understand that? It is science. Fact.

 

[jw3600]

Look, I took PALS, ATLS, BLS, and ACLS four times each this year. I am now a trauma surgeon. Why don't the people at my hospital understand that? It is science. Fact.

But did you win the NLDS? I thought the Giants did.

 

[fancymylotus]

But did you win the NLDS? I thought the Giants did.

Everyone knows the only team that matters are the


new


york


YANKEEEEEEEES



also, where's the original video?

 

[cidem2065]

Look, I took PALS, ATLS, BLS, and ACLS four times each this year. I am now a trauma surgeon. Why don't the people at my hospital understand that? It is science. Fact.

Four times in one year? Those classes are barely tolerable once.

Edit: discovered context, got the joke

 

[Joebird22]

I like how she thinks it matter that she has 3 or 4 different NP degrees. That's like saying you took an EMT certification course THREE times. So obviously you have a bunch of education. This isn't even getting into the fact that the theory of nursing course you took twice a week does not help your diagnostic or clinical acumen.

That would be true if there were 3 different EMT certifications lol....I'm assuming she did a mental health and family NP program....2 different programs

 

[jw3600]

Everyone knows the only team that matters are the


new


york


YANKEEEEEEEES



also, where's the original video?

Page 4. Kind of half way down. This chick looks like she would struggle to organize a filing cabinet much less take care of patients.

Edit: different video. I think the original got pulled.

 

[jw3600]

That would be true if there were 3 different EMT certifications lol....I'm assuming she did a mental health and family NP program....2 different programs

Whoosh.

 

[link2swim06]

Ironic as it's not even in the initial protocol; you have to go out of your way for that sort of stupidity.

You have mid-levels running codes?

I wishing I was making it up...at night time in our ICU it's just the senior resident/intern and whoever else is around. There was of course an attending who was on the phone...just not in house.

I don't think she really knew much about kayexelate and was just someone who wondered into the code.

I explained to her that making him poop the potassium out in 2 days will not really matter if his heart isn't beating in the interim.

 

[link2swim06]

now come on, please tell me you made this up. This cannot be true.........

Now someone please educate me. Is calcium IV not the first line treatment for non-digoxin hyperkalemia associated with acute ekg changes + insulin/D50%w?

To answer your second question...

QRS widening on EKG (or worse): Many would give 1 amp of calcium chloride, 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

No EKG changes or 'just peaked t-waves': Many would just give 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

And then you can address if they need to get potassium out of their body (i.e. lasix, dialysis, and of course STAT KAYEXALATE) or if it was just due to a cellular shift (i.e. DKA).

 

[KnuxNole]

Hey, I'm just saying, NPs in the ED could lead to some trainwrecks, which for some could be hard to believe I guess. Compared to ED physicians who won't do those stuff, the NP would look at their algorithm chart and go "Okie dokie, shotgun approach!".

 

[Instatewaiter]

To answer your second question...

QRS widening on EKG (or worse): Many would give 1 amp of calcium chloride, 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

No EKG changes or 'just peaked t-waves': Many would just give 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

And then you can address if they need to get potassium out of their body (i.e. lasix, dialysis, and of course STAT KAYEXALATE) or if it was just due to a cellular shift (i.e. DKA).

If the QRS is wide, you're pretty late. Any EKG changes, its a good idea to give calcium regardless.
Also, kayexalate is reasonable to give for any of these (except DKA), just know it's not going to act quickly at all. The problem is, once you do the Inuslin and jam it into the cells, it eventually is coming back out so taking it out of the body with kayexalate at the same time is reasonable... or jam in a dialysis catheter and run the CVV

 

[cbrons]

If the QRS is wide, you're pretty late. Any EKG changes, its a good idea to give calcium regardless.
Also, kayexalate is reasonable to give for any of these (except DKA), just know it's not going to act quickly at all. The problem is, once you do the Inuslin and jam it into the cells, it eventually is coming back out so taking it out of the body with kayexalate at the same time is reasonable... or jam in a dialysis catheter and run the CVV

I think the point was that kayexalate monotherapy for a potassium level over 7 with more than a little worrisome ekg changes would be ... insufficient in the emergency setting

 

[TooMuchResearch]

To answer your second question...

QRS widening on EKG (or worse): Many would give 1 amp of calcium chloride, 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

No EKG changes or 'just peaked t-waves': Many would just give 10 units of regular insulin + 1-2 amps of D50, a neb treatment, fluid bolus, and an amp of bicarb (if they are acidotic).

And then you can address if they need to get potassium out of their body (i.e. lasix, dialysis, and of course STAT KAYEXALATE) or if it was just due to a cellular shift (i.e. DKA).

Remember the neb is 4x your standard albuterol neb.

I don't bother with Lasix. Kayexalate doesn't work.

I place the dialysis catheter if they need it.

 

[link2swim06]

If the QRS is wide, you're pretty late. Any EKG changes, its a good idea to give calcium regardless.
Also, kayexalate is reasonable to give for any of these (except DKA), just know it's not going to act quickly at all. The problem is, once you do the Inuslin and jam it into the cells, it eventually is coming back out so taking it out of the body with kayexalate at the same time is reasonable... or jam in a dialysis catheter and run the CVV

I said 'most' as there are certainly practice variations.

Many of the 'expert consensus' and my college (ACEP) suggests not giving calcium until the QRS widens except in specific limited situations. I doubt I could find any prospective RCTs to support that...but that's definitely the predominant teaching where I work. It's pretty easy to do serial EKGs if you are concerned about persistent or worsening hyperkalemia. Calcium isn't always a benign electrolyte.

http://www.acep.org/Education/Conti...Focus-On----Critical-Decisions--Hyperkalemia/

Remember the neb is 4x your standard albuterol neb.

I don't bother with Lasix. Kayexalate doesn't work.

I place the dialysis catheter if they need it.

I don't think kayexalate itself does a whole lot...but repetitive diarrhea can drop your potassium (which kayexalate does a great job at).

Immediate management of hyperkalemia is pretty simple. The next steps in management cannot be generalized. The DKA'er, missed dialysis, and septic shock patient are all going to need different approaches after initial stabilization.

 

[PL198]

hearing you guys talk and I'm like "english plz"

-preclinical student

 

[Ismet]

hearing you guys talk and I'm like "english plz"

-preclinical student

Internal medicine will change all of that.

 

[tiedyeddog]

hearing you guys talk and I'm like "english plz"

-preclinical student

Don't worry, you'll learn all of this through forced repetition aka pimping during one if the fifty times you're grilled on it during clinicals.

And after that you might or might not see it in real life. I still haven't seen the protocol initiated on a real patient.

 

[Ismet]

Don't worry, you'll learn all of this through forced repetition aka pimping during one if the fifty times you're grilled on it during clinicals.

And after that you might or might not see it in real life. I still haven't seen the protocol initiated on a real patient.

I haven't seen it yet either. Usually if anything the patients are hypokalemic and we're repleting K and Mg. But that didn't stop them from going over the treatments for hyperkalemia like 5 times during IM.

Kayexalate is just a fun word to say.

 

[link2swim06]

I haven't seen it yet either. Usually if anything the patients are hypokalemic and we're repleting K and Mg. But that didn't stop them from going over the treatments for hyperkalemia like 5 times during IM.

Kayexalate is just a fun word to say.

Probably because you are seeing low acuity patients and not working in the ER.

Go do a rotation in the ICU and starting admitting patients. Hyperkalemia isn't rare.

On a side note, if they are admitting unstablized pt's with hyperkalemia and EKG changes to the floor for you to round on during your medicine roation your hospital has bigger problems.

 

[Ismet]

Probably because you are seeing low acuity patients and not working in the ER.

Go do a rotation in the ICU and starting admitting patients. Hyperkalemia isn't rare.

On a side note, if they are admitting unstablized pt's with hyperkalemia and EKG changes to the floor for you to round on during your medicine roation your hospital has bigger problems.

Hence why I said "yet." I'm doing an ICU rotation in 4th year. I know it's not rare, I just haven't seen it on the core 3rd year rotations but it's definitely a favorite topic for pimp questions on medicine.

 

[alpinism]

If the QRS is wide, you're pretty late. Any EKG changes, its a good idea to give calcium regardless.
Also, kayexalate is reasonable to give for any of these (except DKA), just know it's not going to act quickly at all. The problem is, once you do the Inuslin and jam it into the cells, it eventually is coming back out so taking it out of the body with kayexalate at the same time is reasonable... or jam in a dialysis catheter and run the CVV

Who's the dinosaur that taught you this?

There is no quality evidence that kayexalate works. The 2 original trials often cited from 1961 were completed without any controls, included multiple confounding variables, a lack of rigorous statistical analysis, and demonstrated minimal if any effect of Kayexalate on serum K levels (Scherr, 1961 & Flinn, 1961). Furthermore, a 1998 study also failed to show a statistically significant difference in serum K levels at 4, 8, and 12 hrs after administration of Kayexalate with sorbitol compared to placebo (Gruy-Kapral, 1998).

In addition to the lack of evidence demonstrating any efficacy, there have been multiple case reports of intestinal necrosis, GI bleeding, and intestinal perforation secondary to Kayexalate (Rogers, 2001 & Rashid 1997).

http://emlyceum.com/2012/04/18/hyperkalemia-answers/

I said 'most' as there are certainly practice variations.

Many of the 'expert consensus' and my college (ACEP) suggests not giving calcium until the QRS widens except in specific limited situations. I doubt I could find any prospective RCTs to support that...but that's definitely the predominant teaching where I work. It's pretty easy to do serial EKGs if you are concerned about persistent or worsening hyperkalemia. Calcium isn't always a benign electrolyte.

http://www.acep.org/Education/Continuing-Medical-Education-(CME)/Focus-On/Focus-On----Critical-Decisions--Hyperkalemia/



I don't think kayexalate itself does a whole lot...but repetitive diarrhea can drop your potassium (which kayexalate does a great job at).

Immediate management of hyperkalemia is pretty simple. The next steps in management cannot be generalized. The DKA'er, missed dialysis, and septic shock patient are all going to need different approaches after initial stabilization.

It doesn't do anything. EM lyceum did an excellent review on hyperK treatment a few yrs ago. See above.

The link between ECG changes and K level is also tenuous at best and highly unpredictable.
FWIW I'd personally start Ca gluconate on any patient with a K >6.5.

 

[tiedyeddog]

As an intern, I've ordered that protocol on give or take 30 patients, about 10 of which we're crashing hard (like intermittent vtach). Lot of missed dialysis going on.

Were you on a renal rotation or something? That's seems like a crazy amount for one year?

 

[tiedyeddog]

Probably because you are seeing low acuity patients and not working in the ER.

Go do a rotation in the ICU and starting admitting patients. Hyperkalemia isn't rare.

On a side note, if they are admitting unstablized pt's with hyperkalemia and EKG changes to the floor for you to round on during your medicine roation your hospital has bigger problems.

I dunno, I did an Icu rotation(neuro Icu, maybe that is why? ), am half way through my ER rotation, did a rotation on neph and still haven't see anyone pull out the insulin, d5, nebs, calcium, and whatever else.

And yes, I go to medical school at a large tertiary center with a very high volume. Just haven't seen it implemented. Have seen and participated in many cardiac and neuro codes but no hyperkalemia protocol.

 

[link2swim06]

Who's the dinosaur that taught you this?

There is no quality evidence that kayexalate works. The 2 original trials often cited from 1961 were completed without any controls, included multiple confounding variables, a lack of rigorous statistical analysis, and demonstrated minimal if any effect of Kayexalate on serum K levels (Scherr, 1961 & Flinn, 1961). Furthermore, a 1998 study also failed to show a statistically significant difference in serum K levels at 4, 8, and 12 hrs after administration of Kayexalate with sorbitol compared to placebo (Gruy-Kapral, 1998).

In addition to the lack of evidence demonstrating any efficacy, there have been multiple case reports of intestinal necrosis, GI bleeding, and intestinal perforation secondary to Kayexalate (Rogers, 2001 & Rashid 1997).

http://emlyceum.com/2012/04/18/hyperkalemia-answers/



It doesn't do anything. EM lyceum did an excellent review on hyperK treatment a few yrs ago. See above.

The link between ECG changes and K level is also tenuous at best and highly unpredictable.
FWIW I'd personally start Ca gluconate on any patient with a K >6.5.

The problem I have with you citing this blog is there are few citations compared to the number of claims they are making. So I have no idea where many of these recommendation or statements are coming from. Maybe many of these thoughts are just their opinion or practice style?

I can tell you the following:

1. Kayexalate does work. Probably not with only one-dose and certainly not immediately. It is a messy drug (literally and figuratively) and does have many nasty side effects. As with any drug you would need to carefully select the patient who might benefit from it. This isn't something I order in the ED and certainly has no use for immediately reducing potassium. This is used for multi-day inpatient stays to remove the potassium from the body if needed.

Per your citations, you have basically just regurgitated the EM lyceum review probably without reading the originally articles, no? Mini rant...not intended to be directed at you...this is the one downside of all these random EM blogs/podcasts popping up. They aren't formally peer-reviewed and allow you to avoid diving into depth on an issue to understand it. So it creates an artificial state where you think you know the literature when you are just applying what you heard incorrectly. This is one of the reasons EM gets so much crap from specialists. We should know the literature better than what some random wordpress blog says about it. /end rant

There are no studies to show it is efficacious in the ED, fine...of the literature I have read on the issue I agree. However, for you to argue that kayexalate that doesn't work at all is not consistent with what I have read or the experts have recommended.

If you don't believe me go to pubmed and search "hyperkalemia kayexalate."

2. Pertaining to calcium. Corey Slovis, one of the author of the article I posted is both the chair of Vanderbilt Emergency Medicine and wrote the Rosen's chapter on hyperkalemia. Not to mention he has published numerous peer reviewed articles on hyperkalemia (search his name on pub med). Even though many of these guidelines are more likely grade c type recs, I don't think the authors of the linked blog have anywhere close to the level of expertise in the topic area. Therefore, I still will argue that the advice in the ACEP piece is more valid and founded in better expert opinion. But follow whatever you think the evidence supports.

 

[link2swim06]

I dunno, I did an Icu rotation(neuro Icu, maybe that is why? ), am half way through my ER rotation, did a rotation on neph and still haven't see anyone pull out the insulin, d5, nebs, calcium, and whatever else.

And yes, I go to medical school at a large tertiary center with a very high volume. Just haven't seen it implemented. Have seen and participated in many cardiac and neuro codes but no hyperkalemia protocol.

You need to be in the MICU to see these cases (or the ED). If a patient in the neuro ICU is also having severe hyperkalemia then they are really having a bad day.

 

[tiedyeddog]

You need to be in the MICU to see these cases (or the ED). If a patient in the neuro ICU is also have severe hyperkalemia then they are really having a bad day.

ah, well forget that then. You couldn't pay me to spend time in the MICU. I only do neuro ICU rotations for my program next year, thankfully for me.

 

[Nesmall2]

The pearl necklace is freaking hilarious. Certified menopause practitioner? So what about the other 2 million things that go wrong with our health? Do they have to become independently certified to be able to adequately treat each one. I just became more skeptical of NPs. Next time I see one I'm going to ask what he/she is certified in.

Right now these are the current certifications for NPs:

View attachment 190961

Haha I think I earned all these merit badges

 

[WingedOx]

Haha I think I earned all these merit badges

They're the "white rings." You'd better have...

 

[Siggy]

Internal medicine will change all of that.

...and at my hospital most of the senior IM residents spaz out at any hyperkalemia and want to throw the entire algorthm at it. K of 5.7 without EKG change? Calcium, insulin, D50, kayexalate. :-/

 

[cbrons]

Who's the dinosaur that taught you this?

There is no quality evidence that kayexalate works. The 2 original trials often cited from 1961 were completed without any controls, included multiple confounding variables, a lack of rigorous statistical analysis, and demonstrated minimal if any effect of Kayexalate on serum K levels (Scherr, 1961 & Flinn, 1961). Furthermore, a 1998 study also failed to show a statistically significant difference in serum K levels at 4, 8, and 12 hrs after administration of Kayexalate with sorbitol compared to placebo (Gruy-Kapral, 1998).

In addition to the lack of evidence demonstrating any efficacy, there have been multiple case reports of intestinal necrosis, GI bleeding, and intestinal perforation secondary to Kayexalate (Rogers, 2001 & Rashid 1997).

http://emlyceum.com/2012/04/18/hyperkalemia-answers/



It doesn't do anything. EM lyceum did an excellent review on hyperK treatment a few yrs ago. See above.

The link between ECG changes and K level is also tenuous at best and highly unpredictable.
FWIW I'd personally start Ca gluconate on any patient with a K >6.5.

Why gluconate? Something about extravasation which went over my head

 

[Nesmall2]

They're the "white rings." You'd better have...

Haha, yea it's been a while, they all looked incredibly familiar and I forgot if I had actually earned most or all of them.

 

[TooMuchResearch]

The problem I have with you citing this blog is there are few citations compared to the number of claims they are making. So I have no idea where many of these recommendation or statements are coming from. Maybe many of these thoughts are just their opinion or practice style?

I can tell you the following:

1. Kayexalate does work. Probably not with only one-dose and certainly not immediately. It is a messy drug (literally and figuratively) and does have many nasty side effects. As with any drug you would need to carefully select the patient who might benefit from it. This isn't something I order in the ED and certainly has no use for immediately reducing potassium. This is used for multi-day inpatient stays to remove the potassium from the body if needed.

Per your citations, you have basically just regurgitated the EM lyceum review probably without reading the originally articles, no? Mini rant...not intended to be directed at you...this is the one downside of all these random EM blogs/podcasts popping up. They aren't formally peer-reviewed and allow you to avoid diving into depth on an issue to understand it. So it creates an artificial state where you think you know the literature when you are just applying what you heard incorrectly. This is one of the reasons EM gets so much crap from specialists. We should know the literature better than what some random wordpress blog says about it. /end rant

There are no studies to show it is efficacious in the ED, fine...of the literature I have read on the issue I agree. However, for you to argue that kayexalate that doesn't work at all is not consistent with what I have read or the experts have recommended.

If you don't believe me go to pubmed and search "hyperkalemia kayexalate."

2. Pertaining to calcium. Corey Slovis, one of the author of the article I posted is both the chair of Vanderbilt Emergency Medicine and wrote the Rosen's chapter on hyperkalemia. Not to mention he has published numerous peer reviewed articles on hyperkalemia (search his name on pub med). Even though many of these guidelines are more likely grade c type recs, I don't think the authors of the linked blog have anywhere close to the level of expertise in the topic area. Therefore, I still will argue that the advice in the ACEP piece is more valid and founded in better expert opinion. But follow whatever you think the evidence supports.






Just to clarify, authoring a textbook chapter doesn't make one an expert in the topic. Many textbook chapters are authored after someone sends an email out asking if anyone wants to write a chapter, someone responds, writes the chapter, a couple of people look it over, it gets printed. I know people 1-2 years out of residency that have authored/edited some of these chapters. I don't know that Slovis is more knowledgeable on hyperK than Swaminathan (editor of EM Lyceum) or any of the other "big name" educators, including many of the blog authors. Everyone knows Weingart "occasionally" goes rogue, but most of the others put together reasonable reviews of the literature and are quick to remind us when they're telling us their own non-evidence based practice patterns.

I start to shift the K. If any QRS widening or any funkiness other than a little T peakiness, calcium goes in. These patients are always on the monitor, so I can watch and listen for alarms. I don't give Kayexalate because it doesn't work in a useful timeframe for me, and I don't like giving people diarrhea in my department (for everyone's sake) if it can be avoided. I think most of us have read that review paper in whatever nephrology journal telling us to avoid Kayexalate unless we've exhausted all other options, and the Cochrane review does not show anything impressive supporting its use.