70y/o F BIB EMS after being found in car next to grocery store. Patient was apparently driving and then suddenly became unresposnive car still in D, and came to halt slwoly at guard rail. On arrival patient being bagged agonal breathing near 40x's/min. She moves all four ext pupils 5mm nonreactive.

VS 210/100, 120, 40, 90% ON 15L NRB, no temp yet just being placed on monitor. (at this point everyone in the room was thinking bleed).

We decide we want to intubate, but first Im caught off guard by the monitor so we snap a quick EKG

EKG 1 - Copy.jpg

What's going on here???

Big gulps time to intubate the patient, lets not use succ, lets throw two amps of bicarb in there immediately, and open the code cart (boos are arising from the nurses), I also ask the EKG tech to stay here.

After bicarb - Copy.jpg

This is the rhthym while infusing bicarb

 Wow this stuff really works, thats after half an amp of bicarb. What's next doctor??

So we gave some calcium CHLORIDE, not gluconate, rmeber three amps of CaGlu=1amp of Cacl and you can give CaCl IVP. So lets see yet another rhythym change

After calcium cholride - Copy.jpg
Cardioversion, bicard - Copy.jpg

Whoops that 1amp of CaCl thew our patient into svt, well by this point shes intubated, shes on propofol lets just shock her. 100J synchronized CV nothing, 150J synchronized Cv nothing,ok ok treat the underlying pathology more bicarb. Whoops again this is the following EKG, we were preparing amiodarone at this point, and she did still have a very strong pulse.

 And our SVT just degenerated into VTACH OH shit, but she still has a pulse she gets another gram of calcium and another ampulse of bicarb and 150 of amio and an amio drip. And this is her final EKG

amiodarone, more calcium and bicarb - Copy.jpg

Wow what a dramatic difference. So now we don't have a K yet because ABG's wont give us a K. I still have no history so what did I do for his lady preemptively?

20mg albuterl neb, 40mg of lasix  (she put out 100cc with a foley), kayexalate (even though i doubt its efficacy), bicarb drop 200cc/hr and an amio drip. I called vascular and said we are going t need a quinton and paged dr. zikos (he's greek and comes in the middle of the night so a crowd favorite).

ABG comes back: pH < 6.96, pCO2 21 (we set the rate at 30 very important on initial intubation she was breathing 40x's minutes beforehand).

Later her Cr comes back at 9.1, K of 7.2, everything else relatively normal

Ultrasound probe showed extremely dilated renal pelvis suggestive of obstructive uropathy, so we get a cat scan. She has bladder CA with obstructive uropathy. She gets dialyzed ph normalizes, she wakes up, her potassium is normal and left the hospital on her own two feet today. AWESOME case of hyperK