G‧N‧M

a 67 y/o male come to ER

bedridden, con's alert, RR smooth, V/S stable, no fever

past history: H/T, stroke

chief complain: 兩天尿不出來.

PE: lower abdomen soft, mild distend, mild tenderness, no muscle guarding.

想法是，放完尿管，洗手收工。

但兩天沒尿尿，好奇有多少尿？

於是手賤拿了sono掃了一下，colon gas，膀胱沒有脹尿？那當然沒有尿？

不放尿管了，做點基本survey，想不到：

ECG came out to be:

<ECG sine wave appearing>

initiated hyperkalemia treatment, and lab data came out later：

after treatment of hyperkalemia, 6 hrs later ECG (2nd):

conclusion:

acute renal failure, cause?

hyperkalemia

<NOTE>

What ECG changes are associated with hyperkalemia?

→the first ECG change seen in hyperkalemia is usually a tall, peaked T wave

   that may occur as potassium values rise to between 5.5~6.5 mEq/dl.

→Loss of the P wave may follow as potassium levels rise to between 6.5~7.5 mEq/dl.

→the most dangerous ECG finding (generally associated with levels of 8.0 mEq/dl) is

   widening of the QRS.

   Which may merge with the abnormal T wave and create a sine-wave-appearing ventricular

   tachycardia.

treatment is based on (a) serum levels, (b) the presence or absence of ECG changes,

(c) underlying renal function.

If the patient has life-threatening ECG changes of hyperkalemia (widening QRS or a sine-

wave-like rhythm), 10% calcium chloride should be given in an initial dose of 5~10 mL

to temporarily reverse potassium's deleterious electrical effects.

Most patients, however, with kalemia usually just require moving potassium intracellularly,

then moving potassium from the body, rather than receiving a potentially dangerous 

calcium infusion.

Key Points:

1. Hyperkalemia is asymptomatic; you must check the ECG.

2. The ECG changes seen as potassium rises are:

    (a) a tall peaked T wave

    (b) loss of the P wave

    (c) widening of the QRS complex

3. Administering glucose and insulin, supplemented by an inhaled beta agonist,

    is the most effective method to drive potassium in to the cell and acutely lower

    serum potassium.

4. Bicarbonate only works to lower serum potassium in acidotic patients.

5. Only give calcium in hyperkalemia for a wide QRS.

參考來源：EMERGENCY MEDICINE SECRETS - fifth edition