Questions about a call....Input appreciated.

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JCEMTB

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Had a call earlier I wish to get some input on. Here's the scoop....oh and its on a Basic truck,

Hx: Kidney CA, Right nephrectomy, HTN, Hyperlipidemia, Anemia

Took a regular dialysis pt. to dialysis, VS the entire time are normal, 110/64 HR 82 and regular Resp 18, pt. has no complaints at all. We dropped him off at dialysis, and 5 minutes later are called to come back and take him to the ER as his HR had shot up to 140 and his pressure had dropped a bit 100/60. Patient still has no complaints, is stable and asymptomatic of well, anything (minus the HR shooting up). Questioning reveals patient has not eaten well for several days. At dialysis we get a BP of 104/60 HR 136. Enroute I get a BP of 94/P(Couldn't Hear) HR 140. At the ER they get a BP of 95/53 HR 140.My question is, what are the possible causes of his HR to just shoot up out of nowhere? His trending suggests his body is compensating, but could the drop in BP be caused by an arrythmia, say SVT as it usually has a rapid onset? Again, he was asymptomatic of anything. Just looking for some input, possible causes. We came up with:

Electrolyte imbalance, specifically hypokalemia, causing the tachycardia, the tachycardia in turn causing hypotension? I thought this possible because the patient had not been eating well, and is a dialysis patient. However, wouldn't that have a gradual onset, not rapid?
 
They freak out when his BP dropped only 10 points? Heck... 95/53 is still only a drop of 15/11... not really anything to be excited about.


He has a history of hypertension, so I would assume he's on something, though apparently not beta blockers. Could have changed his dosage, taken too much, changed the drug, etc etc. Could have had an internal bleed. Heck, could have been dehydrated.


Without an EKG, I'd classify it as sinus tach and not SVT.



Just because it happened in the time he was at dialysis, doesn't mean it was rapid. Could have been happening the whole time and that was just a new sign.
 
JCEMTB said:
Had a call earlier I wish to get some input on. Here's the scoop....oh and its on a Basic truck,

Hx: Kidney CA, Right nephrectomy, HTN, Hyperlipidemia, Anemia

Took a regular dialysis pt. to dialysis, VS the entire time are normal, 110/64 HR 82 and regular Resp 18, pt. has no complaints at all. We dropped him off at dialysis, and 5 minutes later are called to come back and take him to the ER as his HR had shot up to 140 and his pressure had dropped a bit 100/60. Patient still has no complaints, is stable and asymptomatic of well, anything (minus the HR shooting up). Questioning reveals patient has not eaten well for several days. At dialysis we get a BP of 104/60 HR 136. Enroute I get a BP of 94/P(Couldn't Hear) HR 140. At the ER they get a BP of 95/53 HR 140.My question is, what are the possible causes of his HR to just shoot up out of nowhere? His trending suggests his body is compensating, but could the drop in BP be caused by an arrythmia, say SVT as it usually has a rapid onset? Again, he was asymptomatic of anything. Just looking for some input, possible causes. We came up with:

Electrolyte imbalance, specifically hypokalemia, causing the tachycardia, the tachycardia in turn causing hypotension? I thought this possible because the patient had not been eating well, and is a dialysis patient. However, wouldn't that have a gradual onset, not rapid?
Click to expand...

I would expect this patient to be hyperkalemic. Even if the pt isn't eating that much. Remember th pt has only one kidney and it obviously can't keep up. Did the pt have any edema? What was the quality of their pulses? Pt consume ETOH? Hear anything about peaked t waves? Dialysis makes PTs feel Terrble. I could see the hr and drop in Bp as psychosomatic. Did they try laying the pt flat at dialysis? Could be Anemia. I often see PTs get PRBCs along /c HD
 
there is not enough info here to offer anything.

Why is the pt on dialysis?

Did he have primary or secondary HTN?

What kind of CA?

Stage?

cardiomyopathy?

Mets?

What kind of anemia?

Chemo?

What meds?
Sorry, too many variables for anything more than the correction of hyper not hypo K+
 
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sorry ven! I wrote this in a hurry. doh I meant hyper not hypokalemic oops. And apparently not everything I wrote posted. Ven for your questions
-Pt. only has 1 kidney and ESRD
-Right nephrectomy due to Kidney CA
-Not currently on chemo, although finished it within the past couple of weeks
-No Mets
-Unknown if pt. has cardiomyopathy
-Iron deficient anemia
-Meds: Flagyl, Cardura, Lopressor, Ativan

Also, I thought it could have been a combo of dehydration/BP meds as you said Linuss. His skin turgor was rather poor.

I guess this is kind of a silly post given the numerous variables that could cause this and the lack of any ECG or anything being that I was on a Basic truck.
 
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Oh also.....
-on vicodin 325/5
-dialysis tx had not been started
-only given Flagyl the morning before treatment

my mistake about the hypo k+, hyper makes way more sense.

I just get frustrated with myself when I don't know something so I try to get as much information about what I didn't know so I can better understand it. Just trying to improve myself as a provider.
 
Generally hyper K+ causes bradycardia

There seems to be an effort to control his BP with medication, which could take away his ability to compensate if they started dialysis. Accounting for an increase in HR and decrease in BP. With only 1 failed kidney, his RAA cycle could be severely inhibited. (If existent at all between the failure and the lowering of the BP enough to shut of the remaining renal perfusion)

Dehydration is possible if there was minimal intake between dialysis.

Cardiomyopathy or nephrotoxicity as possible side effects of Chemo, both of which would decrease compensation via the decreased ejection fraction or inhibition of the RAA system respectively. ESRD patients are already at risk of inhibition of both RAA and erythropoietin secretion.

The metronidazole causes loss of appetite, which could explain the lack of eating leading to dehydration.

The high BP can cause the myopathy as well.

His anemia could also lead to an attempt to compensate. But Anemia of chronic disease as well as hemolytic damage from dialysis could also compound his hypo perfusion leading to a compensatory response.

Since he is on an antibiotic for an anaerobe, he could be suffering from an early bacteremia and sepsis.

Did he have a catheter or a fistula?

There is every possibility he could have an arrhythmia which led to the decline. Afib is the most common. Was the pulse irregular? Weak? Seem like extra or skipped beats? Heart tones commensurate with pulse?


While about the only electrolyte that can be ruled out is K+ there is also the issue of anxiety, and having some of your blood run through an external circuit.

Your new addition of a synergy between the benzo and the opioid can also reduce BP.
 
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Also,

SVT and Afib can be Dx with a stethoscope.
 
Pt. had a catheter. The pulse was rapid, but strong and regular with no abnormalities.
 
JCEMTB said:
Pt. had a catheter. The pulse was rapid, but strong and regular with no abnormalities.
Click to expand...

A catheter makes an infection more likely, but if it hasn't be in that long, it could be prophylaxis.

If the pulse was strong and regular, that would likely rule out Afob, but not without correlating heart tones.

Measure of JVP might tell you about a potential right sided heart failure, which is most often secondary to left heart failure.

But I think between my last two posts about all than can be figured out has been.
 
MonkeySquasher said:
Okay, I admit, I'm stumped. Thinking about the Na/K pump, I would think the ^K would cause an increase in rate of depolarization/repolarization. Can you explain this?
Click to expand...

Without getting into the biochemistry, histology, and anatomy,

There is an equalibrium in the intra and extra cellular K. This reduces membrane excitability and in the AV node causes a slowing of conduction through it.

Slower conduction, slower rate.
 
Thanks for all the feedback ven I appreciate it, and have been researching more into every possible explanation you gave. Also, I picked up a book about fluid/electrolyte balances to better understand all of that. We went over it in medic class, but very limited.
 
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