Weakness and vomiting for three days

Heart failure with reduced ejection fraction, on ramipril, spironolactone, bisoprolol and furosemide. Type 2 diabetes on metformin. Has been vomiting and passing loose stool since a family meal on Sunday and has kept taking all her tablets.

Stage 1 of 2

Her son brought Dorota Wiśniewska in because she could not get out of her chair this morning. She is drowsy but orientated, dry, and says her legs feel heavy. Bloods have gone to the laboratory and are not back. This tracing was recorded in the resuscitation room.

Tracing 1 of 2 for the quiz “Weakness and vomiting for three days”. — Twelve-lead on arrival in resus, 25 mm/s, 10 mm/mV. Open this tracing in the studio

What does this tracing show?

AHyperkalaemia Correct answer Your answer
BComplete heart block with a ventricular escape rhythm Your answer
CHyperacute T waves of an early anterior occlusion Your answer
DSinus bradycardia with a bundle branch block Your answer

The laboratory result is not back. What do you give now?

ANothing until the laboratory potassium is available Your answer
BCalcium gluconate 10%, 30 ml intravenously Correct answer Your answer
CInsulin 10 units with 25 g glucose intravenously Your answer
DSalbutamol 10 mg by nebuliser Your answer

Stage 2 of 2

The laboratory potassium taken on arrival was 7.6 mmol/L, with a creatinine of 268 umol/L against a baseline of 96. She has had calcium, insulin with glucose, and fluid. Two hours later the potassium is 5.9 mmol/L and this tracing was recorded.

Tracing 2 of 2 for the quiz “Weakness and vomiting for three days”. — Twelve-lead repeated two hours later, 25 mm/s, 10 mm/mV. Open this tracing in the studio

Observations

HR: 66
SpO₂ (%): 97
Respiratory rate: 16
Temperature (°C): 36.4
Systolic BP (mmHg): 112
Diastolic BP (mmHg): 68

Bloods

Glucose (mmol/L): 7.2
Potassium (mmol/L): 5.9
Creatinine (umol/L): 268
Bicarbonate (mmol/L): 18

What does the second tracing tell you?

AThe potassium has been excreted and no further treatment is needed Your answer
BThe narrow complexes show the calcium is still protecting the myocardium Your answer
CThe membrane effects have reversed while the potassium load remains in her Correct answer Your answer
DThe earlier width was rate-related and narrowed as the rate rose Your answer

Weakness and vomiting for three days

The case

On arrival

Observations

Bloods

Diagnosis

Discussion