29-year-old man with history of type 1 diabetes mellitus and currently living in a hotel, presented to the emergency department with 2-weeks of feeling ill with had accelerated and was much worse over the last 2 days. This included a productive cough, subject fevers, and frequent vomiting. He was brought in by his brother, and the patient was appeared ill, was somnolent, confused, and only oriented to self. his blood pressure was 78/43 mmHg, pulse 146 bpm, respiratory rate 26, 37.2deg C, SpO2 96%. An finger stick blood glucose measurement read HIGH. A cardiogram was also obtained.
This is a regular wide complex tachycardia. the first question you need to to determine in these cases is if the patient is stable or unstable. In this situation, the patient was hypotensive with altered mental status. He was electrically cardioverted using the synchronized setting and a voltage setting of 150 J. He was then immediately given 3 ampules of calcium gluconate and 3 ampules of sodium bicarbonate.
This is the correct treatment. The physicians inferred from the severe hyperglycemia that the patient may be hyperkalemic, which was the cause of the wide complex tachycardia. given that he was unstable electrical cardioversion was the first step, quickly followed by calcium to help stabilize the myocardium. The bicarbonate is given to facilitate the intracellular shift of potassium. The patient was additionally treatment with 2 L 0.9% saline bolus, 10 units SC insulin aspart were given.
Immediately after cardioversion the following cardiogram was obtained.
What is most impressive is the peaked T-waves consistent with hyperkalemia. His chemistry panel eventually returned which showed at presentation he had a glucose of 1120 mg/dl and a potassium of 6.6 mEq/L.
Androgue (Medicine 1986;65(3):163) created a formula to predict the potassium at admission in DKA.
K+ = 25.4 – (3.02 x pH) + (0.001 x glucose) + (0.028 x Anion Gap)
However in our case it under predicts the potassium, however the paper gives an excellent reviewing he mechanism of hyperkalemia in hyperglycemia.
Unfortunately the patient’s mental status did not improve significantly, and ultimately required orotracheal intubation and mechanical ventilation. He was admitted to the MICU where he continued on an insulin protocol overnight. About 10 hours after admission his anion gap had closed, and he was transitioned to long-acting insulin glargine. A repeat ECG at this time showed return of a normal sinus.
The patient ultimately did well and was discharged from the hospital.