Hey everyone, welcome back to Static Cardiology here on EMTV. I'll be giving you an ECG rhythm and a scenario. On the bottom of the screen, you'll see a timer for 1 minute and 30 seconds.
This time closely resembles the average amount of time you'll want to be spending on each card during an actual National Registry exam. When the time is finished, I'll be giving you an answer as well as a treatment. Good luck! 3, 2, 1...
This may be a scenario that you've seen in the past. Let's go ahead and first examine the rhythm. and find out what it is.
The first thing I like to do with every rhythm is count the r waves to determine its rate. I'm only seeing four r waves here so the rate is 40 bpm. Next thing I'll do is examine each r wave and see if there's a p wave present. I'm seeing a small one there, there, there, and there. Now at first glance this rhythm may appear ventricular because of its very very wide QRS complex but the presence of a p wave will always indicate a point of atrial cardiac initiation.
The R to R interval appears consistent as well. Because of these factors, I would diagnose this rhythm then as a sinus bradycardia. Now let's go ahead and take a look at the scenario.
So we are called to a private residence by the police department to assist in a welfare check. The patient, a 63-year-old female, has reportedly missed more than a week of dialysis and was found minimally responsive. Your partner obtains the following vital signs, BP of 66 over palp, pulse of 40, respirations 5, and an SpO2 of 84% on room air. Now after reading this scenario it may be a little bit more apparent as to why this rhythm looks the way it does.
This patient is a dialysis patient and one of the primary jobs that the kidneys perform is to actually maintain the balance of potassium within the body. Because this patient doesn't have functioning kidneys, dialysis is required in order to maintain normal serum potassium levels. What you're seeing here is actually a late hyperkalemia. Most people associate hyperkalemia with tall peaked T waves, and this is true. But as the hyperkalemia progresses, you'll start to see a widening of the QRS complex, as well as that large peaked T wave that's still present there.
Eventually, the P wave can disappear, and this will progress into a lethal ventricular dysrhythmia. So this makes more sense in the context of the scenario that this is a sinus bradycardia, but this patient is severely hyperkalemic. Now, back to static cardiology.
The vast majority of your points in static cardiology are scored through adequate treatment, and we must first determine what side of the ACLS algorithm we need to follow. So is the patient stable or unstable? For my unstable criteria, I use the acronym CHAD.
And this of course stands for cardiac insufficiency, hypotension, alteration of mental status, and dyspnea. Based on my patient's current presentation, as well as her vital signs, she is definitely unstable. So my final diagnosis for static cardiology is going to be an unstable sinus bradycardia.
Now let's go ahead and look at the treatment. Now just like with all my other static cardiology cards, I'll begin the treatment by reciting the mantra, scene safe, BSI, IVO2 monitor. The next thing I'll mention is the fact that I'm going to ventilate this patient with a BVM as her respiratory rate is only 5. Because this patient is bradycardic, I'll then consider atropine, 1mg IV push, but as the old saying goes, unstable gets the cable.
More definitive treatment here is going to involve transcutaneous pacing. So what I'll do is I'll... place pads on the patient, turn on the pacer function on my monitor, select my rate, and this can be anywhere between 60 and 100 pulses per minute for ppm, and then I'll increase my current until I achieve electrical capture.
I'll then check a carotid pulse to assure mechanical capture, and if I need to, I can then initiate vasopressors for better hemodynamic control. And of course, I'll end this card by saying rapid transport. Now, that's the end of the static cardiology card, but because because we know this patient is hyperkalemic, I think we should now talk about bonus treatment.
So my bonus treatment for hyperkalemia management of this patient is going to involve a few different medications. The first medication I'll administer is going to be regular insulin and I'll be giving 10 units intravenously followed immediately by D50. Insulin and D50 are used as insulin allows intracellular shift of potassium which should largely be an intracellular ion back into the cell while the D50 will then stabilize the expected drop in blood sugar.
I'll then administer calcium chloride or calcium gluconate, and this will be one gram IV, and this is used to stabilize the cell membrane. I'll then administer sodium bicarb for a little bit more of a intracellular shift of ions, and then I can even administer albuterol, 10 to 20 milligrams nebulized, or further intracellular shift of potassium. The only thing we're missing here is diuresis, or removal of the potassium from the body. Now if this patient had functioning kidneys, we would rely on things like Lasix or furosemide or even K-exolate. But because this patient is end-stage renal, the only way to remove the potassium from the body at this point would be to perform hemodialysis.
So that would be the most definitive removal option for this patient. And that's it! If you like this video, please make sure to subscribe to my channel for more static cardiology. And remember to make your own custom playlists using my cards so you can practice for your national registry exams too. Until I see you next, Have a good rest of your night.