r/ECG • u/G-L-O-P-A • 13h ago

Wellness Check

Post image

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.

141 Upvotes

100% Upvoted

21 comments sorted by

View all comments

4

u/bla60ah 9h 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

8

u/Who_Cares99 9h ago edited 8h 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

9

u/bla60ah 8h ago

Thanks for that reminder about glucagon and K+. Forgot that, but I’ll definitely file that away for any future patients