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Baratloo et al.
elevated potassium level only further worsened this pre- their use in emergency and fatal situations. In addition,
existing conduction abnormality (4,5). because of high probability of significant constipation
Treatment of patients with third-degree AV block depends induced by exchange resins, combination with a laxative,
on the symptoms. A temporary pacemaker will be nec- such as sorbitol, is ordinarily considered. Although gener-
essary in all the patients with CHB, who do not respond ally safe, the combination of a resin with sorbitol has been
to medical intervention. Patients with clinical evidence of reported to cause intestinal necrosis; therefore, it should
hypoperfusion are best treated with transcutaneous pac- be used cautiously and only when necessary (9,14,15).
ing and close clinical assessment. While atropine is often
used in the field, it rarely helps or harms, usually simply Conclusion
alters the conduction ratios without changing the escape Hyperkalemia is a commonly encountered electrolyte ab-
rhythm. The patient should be admitted into an appropri- normality that can lead to life-threatening derangements
ate monitoring unit if acquired or symptomatic third-de- in cardiac conduction. The emergency medicine physician
gree AV block is diagnosed. Initially, external pacing (via and specialist should be aware of the range of dysrhyth-
skin pacing pads) may be successful in urgent cases in the mia attributed to Hyperkalemia, including CHB which is
ED. This is useful as a temporary measure until the patient rare but can occur, especially in patients with pre-existing
stabilizes and treatment of the underlying cause becomes heart failure, conduction abnormalities, or other cardiac
effective or a more definitive pacemaker is placed (7,9). diseases. Institution of effective treatment rapidly and for-
The goal of life-threatening Hyperkalemia treatment is to giveness of traditional non-effective, time consumptive
block its effects on myocyte membrane, cardiac conduc- and sometimes risking full adjustment modalities, such as
tion and initiation of further steps to decrease extracel- sodium bicarbonate infusion or exchange resins that ex-
lular potassium levels (6). Most of the current recommen- clude their use in the emergent phase, can help minimize
dations emphasize that Hyperkalemia should be treated patient morbidity and mortality.
with the appearance of electrocardiographic changes or
when serum potassium levels are higher than 6.5 mEq/L, Acknowledgments
regardless of the electrocardiogram (10). We would like to thank all emergency department person-
The treatment for Hyperkalemia can be thought of in 3 nel of Shohadaye Tajrish Hospital whose help was crucial
distinct steps. The first step is to antagonize the effects of in appropriate diagnosis and management of this patient.
Hyperkalemia at cellular level (membrane stabilization).
Calcium (intravenous calcium chloride or gluconate) can Ethical issues
effectively block the effect of extracellular potassium el- This study is compatible with Helsinki Rules for ethics in
evation on cardiac myocytes within minutes by restoring research studies that was approved by the ethic committee
a more appropriate electrical gradient across the cellular of Shahid Beheshti University of Medical Sciences.
membrane. The second step is to decrease serum potas-
sium levels by promoting the influx of potassium into cells Authors’ contributions
throughout the body. Combination of Glucose and Insu- AB and FR managed the patient in ED and collected the
lin, Beta-2 adrenergic agonists and Sodium bicarbonate data. AR wrote the first draft and collected more data with
drives potassium intracellularly and lowers the extracellu- internet research. AB and SS commented on the final
lar serum potassium level. The third step is to remove po- manuscript and PH provided critical revisions.
tassium from the body. Excessive body potassium can be
removed with sodium polystyrene sulfonate (kayexalate),
whereas hemodialysis represents the definitive method to Summary points
reduce serum potassium levels (5,6,10). ▶ Why is this topic important? Hyperkalemia is one
Sodium bicarbonate infusion is used with the aim of shift- of the curable emergency conditions that can be
ing extracellular potassium to intracellular space by rais- presented with lots of manifestation.
ing blood pH (11,12). In a study by Blumberg et al, no ▶ What does this study attempt to show? It tries to
significant change in potassium levels occurred until 4 discuss one of the rare cases of hyperkalemia that
hours after sodium bicarbonate administration and only is presented with complete heart block as a first
a decrease of 0.35 mEq/L was seen after 6 hours (13). Due manifestation.
to the lack of a quick or sustained decrease in potassium ▶ What are the key findings? We explained risk
levels, routine bicarbonate therapy for the treatment of factors, manifestations, and also treatment options
Hyperkalemia is controversial and it is better to reserve of hyperkalemia-induced complete heart block in a
its use for situations in which severe acidemia is present summary via a case presentation as an educational
case study.
or there is another indication for its administration (10).
▶ How is patient care impacted? This paper reported
Most studies have shown that exchange resins decrease
a correct patient care in an emergency department
serum potassium levels by about 1 mEq/L over a 24-hour
as a guide for all emergency physicians and staff.
period. Therefore, their long time requirement precludes
Journal of Emergency Practice and Trauma, 2014, 1(1), x-x 3
Baratloo et al.