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EKG case: Acutely-ill patient has missed dialysis

What's your assessment and care for a patient with history of renal insufficiency and who is 'not feeling well'?


Article updated August 2, 2017

Each patient encounter requires a thorough assessment in order to determine what underlying medical conditions may be contributing to the patient presentation. While the presentation will help guide the EMS professional in their assessment methods, a baseline EKG should also be considered as a staple in every medical assessment.

This case looks at a life-threatening emergency that can be identified and potentially reversed in the field. Early treatment with notification to the receiving emergency department can prove to be a life saving factor.  

Patient presentation: Male 'not feeling well' after missing dialysis

Medic 31 is dispatched for a "male not feeling well."

Upon arrival at a residence, you are met at the door by the patient's wife. She explains that her husband has not been feeling well for the past 24 hours and has been unable to get out of bed. She shows you in to the bedroom where the patient is supine in bed and appears conscious and alert. He states that he missed a dialysis appointment because he felt so bad. The patient is a 53-year-old male. 

His skin is pale, moist and warm. He denies symptoms of fever, nausea or vomiting, and states that he has not had an appetite. He mentions that he did eat some soup today for lunch. As you begin your assessment, you notice a rapid heart rate.

Past medical history:
 
Renal insufficiency
Type I diabetes
Hypertension

Patient's vital signs: 

Heart Rate: 150 bpm
Respirations: 22
Blood Pressure: 95/58 mm Hg
SpO2: 94 percent on room air 

Allergies:

IV push contrast dye

Meds: 
Enalapril 
Insulin 

Initial EKG (click for larger image):

You ask your partner to perform a baseline EKG. Here is the resulting printout for the 12-lead EKG:


The computed interpretation is:

Abnormal ECG **Unconfirmed** 
***Suspect arm lead reversal, interpretation assumes no reversal 
Atrial fibrillation with rapid ventricular response 
Nonspecific intraventricular block 
Possible Right ventricular hypertrophy 
Lateral infarct, age undetermined 
Inferior infarct, age undetermined

Complete your own interpretation of the 12-lead EKG using the steps recommended by the EKG Club

Patient treatment consideratIons and questions

Based on the presentation and findings, you and your partner quickly load the patient onto the stretcher and begin a 25-minute emergent transport. Consider these questions about the patient's condition and best course of treatment.

  • What are the capabilities of the hospital that impact your choice of facilities for this patient? 
  • What is the rhythm?
  • What are the potential causes for this kind QRS morphology?
  • Does the computed interpretation provide any clues for your consideration?
  • What other EKG findings could have been found in an earlier EKG, if one were taken prior to your arrival?
  • This patient is acutely ill and at great risk for cardiac arrest. What should be done now to potentially stop the progression of his condition and to potentially reverse it?

Patient follow-up: How to recognize hyperkalemia

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