68 y.o. male with weakness: “Treat the monitor, not the patient?”

A recent graduate of our hospital’s paramedic program brought this case to me. Leigh works for Stratford EMS, an excellent local service in Southwestern Connecticut.

(A quick note on the specific details of the case: This patient did not necessarily come to my hospital. Additionally, several features of the case have been altered; some to preserve anonymity, others to simplify the case. The ECGs and other essential aspects are unchanged.)

The Case:

EMS was dispatched for a 68-year-old male with altered mental status. On arrival, however, they found the gentlemen to be alert but disoriented. Per the patient, his legs just “gave way,” and he fell onto the floor. His family found him 30 minutes later, still on the floor, too weak to stand. They called 911.

PMHx: Atrial fibrillation, COPD, CHF, DM2

Meds: Carvedilol, HCTZ, furosemide, metolazone, spironolactone, warfarin, Januvia, Advair, Spiriva
Vital Signs:

  • HR – 91
  • BP – 134/78
  • RR – 24
  • SaO2 – 93% RA
  • BG – 74 mg/dL (4.1 mmol/L)

Exam:

  • Gen: Appears ill
  • Skin: No bruises/abrasions
  • Lungs: Diminished bilaterally
  • Cardiac: No gross murmurs
  • Neuro: Weakness bilateral legs

Electrocardiography:

A rhythm strip was obtained:

STEMI_or_Rhythm

A 12-lead was obtained:

STEMI_or_12-lead

The *** MEETS ST ELEVATION MI CRITERIA *** notification catches your eye, of course!

Discussion:

The nearest 24/7 PCI center is 20 minutes away, while a smaller community hospital (fibrinolysis only, but has an ICU, etc.) is “just around the corner.” What is your transport destination?

Update: The conclusion, with the diagnosis, is now available. Click to go there!

40 Comments

  • Frank says:

    Try Calcium??? Then decide.

  • FB says:

    Calcium. Treat the patient, not the monitor. The patient is screaming hypocalcemia. And the bicarbonate to fix his weakness. Only treat the patient. Ignore the monitor.

    • Ben Dowdy says:

      I was thinking hyperK, but agree with the med choices. I’d probably transport to the community ED…not quite ready to activate a cath lab on this ECG alone.

  • Marco says:

    Hypocalcemia?

    This “wide bizarre” rhythm is almost completely diagnostic of hyperkalemia. The story and past medical history as well… Local hospital for treatment hoping that they don’t freak out and call STEMI.

  • JohnK says:

    Pt’s VS seem stable (hard to go on just on set). I’d go to the PCI once cleared by Medical Control. The pt has a good enough story and the incidence of atypical MI presentation increases with age and diabetes.

  • JE says:

    I’d lean towards ventricular pacer as well. Fairly significant Hx for confounders of 12-lead interpretation, but given the above info I’d treat the patient as they were presenting. I would also await labs from the nearest hospital prior to initiating any drastic med challenges.

  • Seth says:

    +1 hyperK. Looks like sine wave.

  • KevinH says:

    Wide, bizarre, complex with WEAKNESS points to hyperkalemia. Treatment could include: Albuterol, insulin, D50, bicarb, and Calcium (it should be noted that calcium does NOT correct hyperkalemia, merely “buys time” to correct it).

  • Dave Eastman says:

    My first thought was hyperkalemia. If the pt is stable, begin with Ca++ & bicarb. Consider albuterol. Serial 12-leads. Start toward PCI capable facility. If it is hyperkalemia, initial treatment should begin to improve pt’s condition and there is no harm caused from the increased transport time. If there is an underlying MI as well, the cath lab will be needed. I know, kinda wimping out, but…

  • Rodrigo Furtado says:

    1) Change to every lead? STEMI is questionable on my Dx # 6 on a list of 5. IF my recall on this, IF a Global presentation of ST change with QRS Change: a) STEMI is extremely unlikely or NOT STEMI b) start looking for mechanical problems ( tamponade) or chemical/ electrical (electrolyte imbalance or infection)
    2) ” my legs are not working weak” Muscular Dysfunction is it Global, I wonder if some form of rigidity is present but not noted or observed, fine motor skills are gone, I wonder?
    3) TWO K depleting medications, one sparing with a History of Diabetes. It is not noted if the Patient has Kidney insufficiency
    4) GET RID OF THE EKG INTERPRETATION, keep the QRS, QT, ST, PR and Axis, everything else DELETE. Do not look at it, make your interpretation then look. You will naturally lean towards the Algorithms interpretation if you look at it first.
    5) Can you draw a Sine wave or visualize one in your mind superimposed on tracing. Its really bad when you actually see it on paper, the patient is about to die. Why would a shift in electrolytes be bad for muscular function? If you can answer that, then the rest is simple
    6) carvediol can cause neuro motor dysfunction(Hypokinesia) and hypo K

    Conclusion

    If Hyper K, is where I am leaning toward, Calcium, Bicarb, Insulin, Dextrose, Kayexalate, are options. Most of us are able to use the Bicarb, and Calcium. The Dextrose works if you can give insulin. And as far as I know most EMS services do not carry insulin. In any case the primary goal here is to start the return of the proper Na, CA, and K levels extracellular and intracellular. Dubin has a good discussion on this, with Hypo and Hyper K/Ca with EKG interpretation

    Now we need to consider Infection or trauma. From what has been given trauma after the fact to cause the EKG trace is highly unlikely. Infection? Well then we must consider Bacterial or Viral, and if this patient lives in Connecticut then consider Lyme Disease.
    Ultimately with no current airway compromise or perfusion my inclination is the Closest facility with a Cardiac ICU and Cath lab.

  • jason says:

    I’m with Dave Eastman on this. I think it’s hyper K+ and will treat as such. But I’ll do that will I head to the PCI capable facility. Do I think there is an underlying STEMI? Nope, I sure don’t. Do I know the computer has a hard time with false positives? yup. Am I willing to be the poor SOB who printed out a 12 lead that said “STEMI” and didn’t go to the PCI facility when I was fully capable of the intial management of my patient? Nope- not this guy! PCI center consult for a guy who doesn’t need it. They were probably slow today anyhow 😉

  • Anthony Garlick says:

    So my working clinical impression would be hypoglycaemia with possibly dehydration and an electrolyte imbalance.
    Reasoning for this is that the patient frusemide and metolazone are both diuretics are known to cause these problems.
    ECG does have a wide and bazar QRS complex with ? ? AV disassociation plus what looks to be peaked T waves supporting hyperkalemia.
    Plus there are added risks of electrolyte imbalance due to his use of beta blockers that can cause a shift of potassium from the intracellular to the extra cellular space.
    There is also some risk that this patient is DKA.
    Although serious the patient is non time critical.

    I’d first of all like to reverse his hypoglycaemia with simple oral glucose. Take his temperature and manage this as found. Then gain some more detailed history.
    Transport to community district general, who are more than capable of dealing with this patient. This patient does not meet any PPCI criteria.
    Treatment on route – we don’t carry insulin so are unable to give insulinr- in glucose infusion.
    However may consider nebuliser salbutamol to reduce potassium.
    We do not carry bicarbonate however I would not give even if we did as the benefits of giving this do not outweigh the large risks of administrating.
    Monitor on route.

  • UK Student Para says:

    Am I really the only one considering CVA in my diffential diagnosis? Hx of AF puts the Pt at increased risk of a clot and Warfarin puts him at increased risk of a bleed. Where I come from we do not have a computerized rhythm interpretation on our ECG which I really like because it makes you better at interpreting them. To me it looks like a paced rhythm (but I am no cardiologist). I would send the ECG and story through to the consultant at PCI and start heading for the nearest ED with CT or MRI and a stroke unit.

  • Harrison says:

    Potassium, not calcium

    That’s my vote.

    I can’t wait until 10 years from now when we will get something like POC blood testing in the rigs. Makes life much easier!

  • Bever says:

    cardiomyopathy

    • Nathan says:

      Much more worried about HYPERkalemia than hypokalemia. Extreme wide QRS + Peaked T Wave is strongly indicitive of HyperK

  • Danny - EMT - Aide says:

    JMJ
    Treat for hypokalemia: Advocate for ER to further evaluate Myotonic dystrophy(MD2) as symptoms closely match chief complaint.

    IV D5W KVO – slowly rehydrate to avoid aggravating preexisting CHF Closest facility

    Chief complaint weakness, and legs giving out.

    PT history.
    The list of medicines raised a red flag. HCTZ and furosemide used together can deplete electrolytes very quickly. This guy is taking three diuretics with no potassium supplement.

    Hypo-k
    The fatigue and muscle weakness spell hypo-k. Would expect palpitation and irregular rhythms. With a heart rate of 91 and possible afib he is a good candidate. Hyper-k would expect slower heart rate. How slow? I don’t know, but closer to bradycardia not tachycardia.

    MEDS – diurectics x3
    – HCTZ
    – furosemide
    – Spironolactone

    ECG changes of hypo-k long PR interval. T wave inversion. ST depression. U waves?

    Let me know the outcome so I can learn something for Pete sake.

  • Dave says:

    From reading the comments one thing is clear. There needs to be more education. What’s on that EKG tracing is something most medics will only rarely see, and some will never see. Low volume scenarios like this can always be tricky.

    And all this armchair quarterbacking aside, in the hospital we don’t diagnose electrolytes solely by the abnormal EKG. They check lab results. An bag can give us a result in 2 mins with stat lytes.

    Rapid transport should be emphasized for situations that you can’t substantially correct in the prehospital environment. Scoop and run, by itself, is rarely the answer but it’s usually part of the answer.

  • Matt Hart says:

    I would first give bicarb and calcium to rule out hyperkalemia while enroute to STEMI center.

  • Richard says:

    Appears to be acute MI based electrolyte imbalance, if patient was not presenting with chest pain and S.O.B. I would transmit 12 lead to nearest facility and advise M.D. or P.A.C. of patient condition and current presentation.I would initiate oxygen via nasal cannula @ 2 lpm to maintain sats, and start a lock for med administration if needed. Patient condition may be result of other Illness or injury, could be pneumonia or COPD excerbation.

  • Nicole G says:

    Potassium is the most likely the problem. There are 11 drug interactions with his meds. Seven are related to potassium and/or electrolyte imbalances. Treat your patient not the monitor.

  • PandaMedic says:

    It’s great to see so many different points of view and styles, it’s sad that so many of us are being critical and condescending towards other practitioners. Dave has a point, in that more education is needed, but there is something to be said for everyone who is here, reviewing these case studies and actively discussing. We need more of that in our community and less criticism of each other.

    As for this patient’s case, my immediate suspicion was also hyperkalemia. In my region, we have the ability to transmit our 12 leads to the Cath lab hospital and get direction. I personally would probably transmit the 12 Lead and confer with a doc, while transporting to the Cath lab hospital, as he could still be seen in the ED there. The argument could be made however, that if it’s just hyperkalemia, without an underlying Neuro event or MI then the patient would benefit from being seen in the ED ‘just around the corner’, for this case study.

  • Hollywood Mike says:

    ALS weakness and fall. Mental status is such that he remembers falling. I’m not going to get all excited about this tracing. I’m treating the guy for his complaint and watching him like a hawk during transport. I’ve seen some aberrant conduction that makes this ECG look like NSR so I’m jaded by experience (need comparative tracing). His V/S are not too bad and you can’t run a BMP (labs) in the back of the bus… so I’m gonna relax and treat the patient. He’s not showing any other CLINICAL signs of an acute MI (C/P, N/V, diaph., SOB, etc.)so I’m going around the corner.

  • david says:

    Looks like sine wave. QRS >.15 tall peaked T waves prolonged PRI, indicative of hyperkalemia.
    Calcium, bicarbonate, 50% dextrose perhaps even some albuterol, insulin at the Ed

  • Billy Bob says:

    Well I will lean with Dave and go with more education; this is a classic sine wave EKG and with more education hopefully we all could spot this from across the door because again as Dave said this is something rarely seen in EMS if at all; this is the ONE TIME I will advocate for treating the monitor! Most of us are agreeing we have hyper K and if so then we now have cardiac instability evidenced by our EKG. Recent research/evidence has suggested that Bicarb is just about useless (from a prehospital perspective) and especially for potassium it just doesn’t move the K like we seem to think/we were taught. Albuterol can be an option but it takes a lot (approx 20 mg) to even see a serum change (how many of us actually carry that much or have a SVN capable of holding that)? Not many of us are carrying insulin so that’s out, you could try giving dextrose in an effort to get the body to do it’s own thing with the insulin. Our best bet is Calcium I carry CaCl so that’s what I’ll go with if you carry gluconate then give that if you carry both I’d go with the chloride secondary to being readily released and having more elemental Ca. Also I think it’s worth pointing out here that again research/studies have shown that EKG changes DO NOT correlate with serum K levels (which again was once taught/thought) so for all we know he could be sitting at 9! or who knows maybe even a 5.9? I spose the answer to the question would be I’d go with the community hospital.

  • Colleen says:

    Allergies? O2, combivent, Calcium. Repeat 12lead ekg. 2nd set of signs. Depending on 2nd Ekg and 2nd set of signs with combivent, reassessment of patient after interventions. Depending on reassessment, 2nd/3rd VS, and 2nd EKG, would determine my decision on where to transport. Per Massachusetts protocols.

  • steve says:

    I have seen this before except it was worse. Based on 3 diuretics and presence of wide bizarre ecg I would go with hyperkalemia . This pt requires electrolyte balancing not a PCI

    My pt presented Brady, hypotensive , simular morphology ecg with pauses and did not respond to fluid atropine or pacing ended up actually going to a PCI faculty that manages his electrolyte imbalance right in front of me. With in 20 min off the pacer nice tight QRS we don’t carry ca in future will patch for bicarb

  • Nathan says:

    This is huuuugely wide. Thinking hyperkalemia. Start with Calcium. Not going to hurt anything with it – and may save the patient.

  • Karl Brennan says:

    Definitive case of hyper K treat with lasix, albuterol, calcium, dextrose and insulin if your unit carries it. Been there seen it before.

  • Random Medic says:

    He’s stable. He can be stable for another 20 minutes. Not one of us knows what his electrolytes are, so any treatment is a gross guess (Is that in anyone’s protocols?).

    Take him to the PCI center. Why? If his lytes and enzymes come back normal, he may not get cath’ed tonight, but may well get cath’ed tomorrow. Save him the cost of another ambulance transfer, as he is stable.

  • Thorn P says:

    Yeah it could be hypekalemia, it could be atypical mi, why not go to the pci capable hospital its only 20 min. You dont have to activate cath lab but if it turns out pt needs it he is there already. Pt vitals are stable enough to go the distance.

  • David Cokely says:

    Stat calcium iv 1g sodium bicarbonate 50meq albuterol 5mg via hhn…im assuming no insulin in the blance so re-evaluation vitals and 12 lead after calcium and bicarbonate while chilling on albuterol…im aggressive as most but this one requires a phone call my friend but to answer the question Cath lab

  • SFL Medic says:

    Destination: ED with most to offer.
    He’s 68 and weak. I’m in Florida…we have people with their favorite Dx on their car tags around here, so that doesn’t bother me. Neither does diminished lungs.
    Altered mental status does. And the ECG looks like an old oscilloscope…which I’ve used in the field (MRL)…which tells me high K+.
    If he was brady I’d consider Ca++ but he ain’t so I wouldn’t.
    Treat with O2 and deisel.

  • Matthew says:

    I lean toward what jason said above – Going to the PCI Hospital, but not activating the lab yet. Go with the Hyper K treatment enroute.

  • Jessica says:

    the bizzare complexes coupled with the fact that the patient takes a potassium sparing diuretic make me think hyperkalemia

  • G says:

    Wide qrs, no P waves, positive aVR. Terminal r wave, weakness = hyperkalemia.

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