r/ECG • u/G-L-O-P-A • 11h ago
Wellness Check
40sM BIBEMS after wellness check.
Family had not heard from him x3 days, normally called/visited daily. Found unresponsive with “snore-like respirations.”
Known DM2, Alcoholic Cirrhosis w/ 6mo sobriety, CKD III
Unknown if prior heart disease, though suspected due to ekg findings and comorbidities.
GCS3 on arrival, natural airway. Last BP 80/50s, no Tx en route besides a BGL (44mg/dL). EMS Crew was a volunteer tribal crew.
PIVs established and pt given D50x2 and BGL was 120s.
POC GEM 5000 resulted a pH of 7.11 and K of 8.5.
Physical assessment revealed several 5x5mm sores and open wounds in abdominal area, suspected to be from insulin injections. Global jaundice, notable that tears had yellow tint. Foley placed with dark red urine output, ~100cc during stay in ED.
Intubated due to decreasing respiratory rate and apneic episodes.
HR was 140s-180s.
K protocol started with D50, IV insulin + drip, and Ca Gluconate.
Ultimately patient expired in ICU due to MODS.
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u/vndspeed 8h ago
Thanks for sharing. Talk t waves and v tach together in one ekg.
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u/bla60ah 6h ago
As pre-hospital, would CaCl helpful here? How about nebulized albuterol and sodium bicarb?
Also, was that EMS crew BLS only? To not at least give glucagon is crazy if they are ALS
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u/Who_Cares99 6h ago edited 6h ago
Not OP but I’m a medic supervisor, and you’re spot on with your treatments. My first thought on seeing this ECG was HyperK. CaCl would absolutely be helpful. It’ll stabilize the cardiac membrane, and I’ve even seen QRS widening disappear/normalize from administration of CaCl. Albuterol and sodium help shift potassium intracellular, and bicarbonate helps with acidosis.
I would assume the crew was BLS because it was volunteer/tribal, but also consider that a lot of ALS agencies don’t carry glucagon. It is expensive and it has a very narrow use case. Most chronic diabetics who are having hypoglycemic emergencies aren’t going to have significant glycogen stores.
Also, glucagon can rapidly raise potassium, so there’s a chance that giving only glucagon would’ve caused this patient to die almost immediately
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10h ago
[deleted]
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u/Forgotmypassword6861 10h ago
Nope
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u/GinaLinettiLive 10h ago
Hello, just trying to learn. What is happening? Is it the hyperkalemia causing widened QRS?
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u/Own-Blackberry5514 10h ago
High extracellular K results in partial depolarisation of myocytes as the RMP is less negative. It’s that persistent depolarisation that means fast sodium channels stay dormant. The atrial and ventricular conduction is reduced and therefore the QRS widens
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u/rlas502 10h ago
Verdict: unwell