Your patient is a 37 year old female brought in by her brother.Her brother states that the patient has been “sick at home long time” and has “bad kidneys”. You note the patient requires total assistance to get out of the hospital wheelchair into the bed due to weakness and severe respiratory distress.  She is noted to have pronounced JVD along with obvious facial and lower extremity edema. Her brother states patient is typically comes to another ER to receive weekly emergent dialysis, but has not gone for the last several weeks days due to transportation issues that have made it inconvenient for family members to bring her. He states she has been ill at home for the last week with progressive nausea, vomiting and shortness of breath. She has had no fever, chills, cough, CP, diarrhea, or other pertinent complaints on ROS. Apart from chronic kidney disease of unknown etiology, she has no other medical history.

With the provided history, what are you expecting in the vitals and physical?

  • BP: 170/110
  •  HR: 120
  • RR: 30
  • SpO2: 82% RA. Comes up to 94% on non-rebreather at 10L.

What studies would you want to have conducted as soon as possible?

An EKG is taken at the bedside. Click to View:

The EKG shows peaked T waves, a classic sign of hyperkalemia and a common problem in patients with end stage renal disease who are behind on their dialysis treatments. There are many options for treating hyperkalemia including insulin+dextrose, beta 2 agonist nebulizers such as albuterol, calcium gluconate and bicarbonate. Kayexalate, once a mainstay of hyperkalemic management has fallen out of favor by many emergency physicians due to a lack of evidence of its efficacy. Hyperkalemia will begin to manifest on EKG as peaked T waves at a serum level of 5.5 mEq/L and can cause cardiac arrest at a level of 9 mEq/L. Of course in this patient, the definitive treatment will be dialysis.