Freeman Kalev, Feldman James A, Mitchell Patricia, Donovan Jacqueline, Dyer K Sophia, Eliseo Laura, White Laura Forsberg, Temin Elizabeth S
Department of Surgery, University of Vermont College of Medicine, Burlington, VT, USA.
Acad Emerg Med. 2008 Mar;15(3):239-49. doi: 10.1111/j.1553-2712.2008.00058.x.
To assess the time to treatment for emergency department (ED) patients with critical hyperkalemia and to determine whether the timing of treatment was associated with clinical characteristics or electrocardiographic abnormalities.
The authors performed a retrospective chart review of ED patients with the laboratory diagnosis of hyperkalemia (potassium level > 6.0 mmol/L). Patients presenting in cardiac arrest or who were referred for hyperkalemia or dialysis were excluded. Patient charts were reviewed to find whether patients received specific treatment for hyperkalemia and, if so, what clinical attributes were associated with the time to initiation of treatment.
Of 175 ED visits that occurred over a 1-year time period, 168 (96%) received specific treatment for hyperkalemia. The median time from triage to initiation of treatment was 117 minutes (interquartile range [IQR] = 59 to 196 minutes). The 7 cases in which hyperkalemia was not treated include 4 cases in which the patient was discharged home, with a missed diagnosis of hyperkalemia. Despite initiation of specific therapy for hyperkalemia in 168 cases, 2 patients died of cardiac arrhythmias. Among the patients who received treatment, 15% had a documented systolic blood pressure (sBP) < 90 mmHg, and 30% of treated patients were admitted to intensive care units. The median potassium value was 6.5 mmol/L (IQR = 6.3 to 7.1 mmol/L). The predominant complaints were dyspnea (20%) and weakness (19%). Thirty-six percent of patients were taking angiotensin-converting enzyme (ACE) inhibitors. Initial electrocardiograms (ECGs) were abnormal in 83% of patient visits, including 24% of ECGs with nonspecific ST abnormalities. Findings of peaked T-wave morphology (34%), first-degree atrioventricular block (17%), and interventricular conduction delay (12%) did not lead to early treatment. Vital sign abnormalities, including hypotension (sBP < 90 mmHg), were not associated with early treatment. The chief complaint of "unresponsive" was most likely to lead to early treatment; treatment delays occurred in patients not transported by ambulance, those with a chief complaint of syncope and those with a history of hypertension.
Recognition of patients with severe hyperkalemia is challenging, and the initiation of appropriate therapy for this disorder is frequently delayed.
评估急诊科（ED）中严重高钾血症患者的治疗时间，并确定治疗时机是否与临床特征或心电图异常相关。
作者对实验室诊断为高钾血症（血钾水平>6.0 mmol/L）的ED患者进行了回顾性病历审查。排除心脏骤停患者或因高钾血症或透析而转诊的患者。审查患者病历以确定患者是否接受了高钾血症的特异性治疗，如果接受了治疗，与开始治疗时间相关的临床特征有哪些。
在1年期间发生的175次ED就诊中，168例（96%）接受了高钾血症的特异性治疗。从分诊到开始治疗的中位时间为117分钟（四分位间距[IQR]=59至196分钟）。7例未治疗高钾血症的病例包括4例患者出院回家，高钾血症诊断遗漏。尽管168例患者开始了高钾血症的特异性治疗，但仍有2例患者死于心律失常。在接受治疗的患者中，15%记录的收缩压（sBP）<90 mmHg，30%的治疗患者被收入重症监护病房。血钾中位值为6.5 mmol/L（IQR=6.3至7.1 mmol/L）。主要主诉为呼吸困难（20%）和乏力（19%）。36%的患者正在服用血管紧张素转换酶（ACE）抑制剂。83%的患者就诊时初始心电图（ECG）异常，包括24%的ECG有非特异性ST段异常。T波高尖形态（34%）、一度房室传导阻滞（17%）和室内传导延迟（12%）的表现并未导致早期治疗。生命体征异常，包括低血压（sBP<90 mmHg），与早期治疗无关。“无反应”的主要主诉最有可能导致早期治疗；未通过救护车转运的患者、主要主诉为晕厥的患者和有高血压病史的患者出现治疗延迟。
识别严重高钾血症患者具有挑战性，针对该疾病的适当治疗启动经常延迟。
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