Marked Symptomatic Bradycardia Associated with Profound Hyperkalemia

Abstract

Background and objectives: Hyperkalemia is a common disorder presents to Emergency Department (ED) with different type of presentations, one of them is cardiac dysrythmia which can be lethal if potassium level is not normalized quickly and cardiac cells stabilized by calcium in appropriate manner. We hypothesize that administration of calcium and potassium lowering drugs will prevent the need for aggressive intervention for patient with sever hyperkalemia and very slow heart rate with decrease level of consciousness. Design and setting: Prospective, patient presented to academic emergency department. Patient and method: On arrival to the emergency department, patient was confused with a lethargic mental status and pulse rate of 41 beat per minute. Blood samples were sent for immediate determination of venous blood gas (VBG) concentrations, which showed potassium concentration of 7.85 mmol/L. The patient was immediately started on hyperkalemia treatment including 2 g calcium chloride was administered intravenously (IV) over 5 minutes. The patient started to regain consciousness and recognize her family with 10 minutes of these treatments. Results: A repeat ECG showed atrial fibrillation, which is similar to the patient's baseline ECG before this admission. Repeat VBG results 90 minutes later showed pH 7.22, Pco 2 39.8 mm Hg, Po 2 26.5 mm Hg, HC0 3 15.9 mmol/L, and potassium 6.00 mmol/L. These interventions led to an almost immediate resolution of the sever bradycardia without the need for temporary cardiac pacing. Conclusion: Life-threatening hyperkalemia should be suspected in any patient with acute onset bradycardia who presents to the emergency department. Blood potassium concentration should be determined immediately by rapid point-of-care tests for an early diagnosis and appropriate medical treatment. Sufficient agreement is found in potassium levels obtained from a chemistry laboratory analyzer and a VBG analyzer.

Polypharmacy in elderly: BRASH syndrome mimicking complete heart block with atrial fibrillation

“…The bradycardia is explained by the interplay of beta blockers and hyperkalemia. Even though true second and third-degree atrioventricular (AV) block have been described in hyperkalemia [5], they are uncommon because the P wave usually disappears before such advanced AV block occurs [6]. On the other hand, the manifestations of hyperkalaemia in the elderly may not accurately correlate with the degree of hyperkalaemia [7].…”

Outpatient Drug Treatment With Fluconazole and Verapamil Leading to Symptomatic Bradycardia and Intensive Care Unit Admission

“…Hyperkalemia itself causes conduction abnormalities including left bundle branch block or AV block. 10,11 It also causes accumulation of AV node blockers (propranolol and verapamil) in a syndrome known as BRASH (bradycardia, renal failure, AV blocker, shock, hyperkalemia) syndrome. It occurs in the context of renal failure and hyperkalemia while on AV nodal blockers.…”