65 Years Old Male, Elevated Potassium Level with Cardiac Arrhythmia

A 65-year-old-male with a history of cerebrovascular accident from 2 weeks was referred to our hospital with the complaints of diminished appetite and drowsiness since last night. He is a smoker since past 30 years. He had no history of hypertension and diabetes mellitus. On examination, his blood pressure was 140/40 mmHg, pulse was irregular and the rate was 52/min, SPO2 98% with O2. On cardiac auscultation, s1 and s2 were clear and audible.

  

On admission, patients electrocardiogram demonstrated irregular rhythms with right bundle branch block and left axis deviation (figure 1). 

Figure 1

 Laboratory results showed pH 7.43, hemoglobin 9.2 gm%, total leucocyte count 19800/mcL, serum K+ 7.5 mEq/L, serum urea 176 mg/dl, serum creatinine 3.6 mg/dl while his liver function tests were normal. Patient’s chest radiograph showed bilateral bronchopneumonia (figure 2).  

Figure 2

Echocardiography showed concentric left ventricular hypertrophy with the ejection fraction of 60%. The patient was immediately given Inj. calcium gluconate and started on 25% dextrose saline combined with 10 units’ human insulin intravenously. Azithromycin was continued empirically along with other supportive management. On the same day around 8 PM serum K+ level came down to 6.8 mEq/L and his repeat electrocardiogram showed a sinus rhythm (figure 3). 

 

Figure 3

Management of hyperkalemia was continued and subsequent measurements showed improvement in serum K+ levels from 6.1 mEq/L (2^nd day), 4.9 mEq/L (3^rd day), 4.6 mEq/L (4^th day), to 4.4 mEq/L (5^th day) and repeat electrocardiogram showed sinus rhythm (figure 4). 

Figure 4