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Hypokalemic Arrest

Hypokalemic Arrest. Eric Lavonas, MD, FACEP Carolinas Medical Center Charlotte, NC. Patient presents with…. H/O schizophrenia Acute-on-chronic overdose 100 pills of a single medication Time of ingestion: ~45 min PTA No symptoms. Vital Signs. P 70 R 16 BP 120/80 T 36.1  C.

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Hypokalemic Arrest

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  1. Hypokalemic Arrest Eric Lavonas, MD, FACEP Carolinas Medical Center Charlotte, NC

  2. Patient presents with… • H/O schizophrenia • Acute-on-chronic overdose • 100 pills of a single medication • Time of ingestion: ~45 min PTA • No symptoms

  3. Vital Signs • P 70 • R 16 • BP 120/80 • T 36.1C

  4. Now the Fun Begins • Sudden cardiac arrest • Wide complex tachydysrhythmia • No pulse • Unknown if Torsades de Pointes • Rapid defibrillation & intubation • P 60 • BP 70/50

  5. Pre-Arrest Post-Arrest 200 msec 240 msec

  6. Laboratory Abnormalities • Profound hypokalemia • Mild metabolic acidosis • Respiratory alkalosis from vent • Other minor abnormalities • Creatinine 1.2 mg/dl • Glucose 178 mg/dl

  7. Post-Arrest Therapy • Dopamine • Poor response • Norepinephrine • BP improved • 4 gm MgSO4 • Potassium, potassium, potassium • 300 ml (154 mEq) hypertonic NaCl

  8. 200 80 Effect of Hypertonic Saline Before After

  9. QT = .640s; QTc = .500 QT.440; QTc.469 QT Prolongation Before After

  10. Inpatient Course • Potassium still low • Aggressive replacement over 11 hours • Weaned off pressors • Did well

  11. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  12. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  13. Anti-Dysrhythmics • Class I: Block Na entry • Ia: Block Na in and K out • Ib: Block Na in • Ic: Block Na in, Ca in, and K out • Class II: β receptor antagonists • Class III: Block K out • Class IV: L-type Ca channel antagonists Vaughn-Williams EM and Singh BN, Cardiovasc Res 6:109 (1972)

  14. Na channel blockade Ca in, K out Na in K out

  15. Sodium Channel States • Resting (Closed) • Open • Inactivated (Closed) • Refractory

  16. Sodium Channel States

  17. Frequency-Dependent Block • Class Ia: τrecovery 1-10 sec • Class Ib: τrecovery < 1 sec • Class Ic: τrecovery > 10 sec Weirich J, Antoni H, J Cardiovasc Pharmacol 15:998-1009 (1990)

  18. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  19. QT = .640s; QTc = .500 QT Prolongation

  20. K efflux blockade Ca in, K out Na in K out

  21. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  22. Relative Bradycardia • β-receptor antagonists • Calcium channel antagonists • Digitalis and related glycosides • Central α-2 agonists • Cholinesterase inhibitors • Mitochondrial toxins (e.g. CN) • Sedative-hypnotics • End-stages of cocaine, TCA’s, etc.

  23. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  24. Hypokalemia • Increased urinary losses • Most diuretics • Renal toxins (toluene, aminoglycosides) • Licorice • Extra-renal losses (diarrhea) • Exchange with another cation • Sodium polystyrene sulfate (Kayexalate™) • Sodium penicillins

  25. Hypokalemia • Intracellular sequestration • Enhanced entry • Catecholamines • Insulin/glucose • Barium salts • Thyrotoxicosis

  26. Hypokalemia • Intracellular sequestration • Blocked release from IK channels • “Pure”:Dofetilide, Ibutilide

  27. Hypokalemia • Intracellular sequestration • Blocked release from IK channels • “Pure”:Dofetilide, Ibutilide • “Less selective”: Disopyramide, flecainide, procainamide, quinidine

  28. Hypokalemia • Intracellular sequestration • Blocked release from IK channels • “Pure”:Dofetilide, Ibutilide • “Less selective”: Disopyramide, flecainide, procainamide, quinidine

  29. Hypokalemia • Intracellular sequestration • Blocked release from IK channels • “Pure”:Dofetilide, Ibutilide • “Less selective”: Disopyramide, flecainide, procainamide, quinidine • Amiodarone, bretylium, propafenone, sotalol

  30. Key Elements • Wide QRS • Prolonged QTc • Relative bradycardia • Hypokalemia

  31. The Sicilian Gambit Task Force of the Working Group on Arrhythmias of the European Society of Cardiology. The Sicilian gambit. A new approach to the classification of antiarrhythmic drugs based on their actions on arrhythmogenic mechanisms. Circulation 1991;84:1831-51.

  32. Hints & Clues • Pill form • Medication • Prescription? Herbal? • Available in bottle of 100 • Cardiac arrest precedes AMS • Recovery in 26 hours

  33. Closing in… Quinine Quinidine Disopyramide Chloroquine Antipsychotics Amiodarone Procainamide Sotalol

  34. Closing in… Quinine Quinidine Disopyramide Chloroquine Antipsychotics Amiodarone Procainamide Sotalol GI Effects Tachycardia Tachycardia Tachycardia, sedation Onset delayed Onset delayed No Na Ch block; no hypoK

  35. Chloroquine • Na channel blockade • Present at low heart rate • K efflux blockade • QT prolongation • Profound hypokalemia • Relative bradycardia • Hypotension

  36. Drug Information

  37. Patient presents with… • H/O schizophrenia • Acute-on-chronic overdose • 100 pills of a single medication • Time of ingestion: ~45 min PTA • No symptoms

  38. Drug Information

  39. Hydroxychloroquine Overdose

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