From Missed Hemodialysis to Multiple Arrhythmias

From Missed Hemodialysis to Multiple Arrhythmias

Case Presentation

A 78-year-old male, known case of Chronic Kidney Disease on maintenance hemodialysis, presented to the Emergency Department with dizziness and lethargy complaints about 2 days. He had missed his last hemodialysis session due to personal reasons. We could not elicit any further history details as was significantly dyspneic (no bystanders with him at the time of presentation). Hence, the patient was received in Bay 1 for immediate resuscitative measures. The patient was afebrile, conscious, and well oriented, but unable to communicate because of severe dyspnea.


HR – 142 beats/min
BP – not recordable
RR – 36 breaths/min
SpO2 – poor tracing, intermittently showed 98% on room air (15 LO2 via Non Rebreathing Mask was initiated nevertheless)


ECG on presentation
Monomorphic ventricular tachycardia

He was immediately connected to a defibrillator in anticipation of possible synchronized cardioversion. Simultaneously, the cause of the possible rhythm was being evaluated for and a thorough examination was carried out. On examination, his lung fields were clear. His left arm AV Fistula had a feeble thrill on palpation.

In suspicion of hyperkalemia as the cause of VT, patient was immediately started on potassium reduction measures while the point of care ABG report was awaited. He was treated with salbutamol nebulization 10mg, sodium bicarbonate 50 ml IV and 10% calcium gluconate 10ml IV. In view of hemodynamic instability, he was also started on intravenous noradrenaline infusion.

ABG Findings

pH – 7.010, pCO2 – 20.8 mmHg, pO2 – 125 mmHg, HCO3 – 7 mmol/L, Na – 126 mmol/L, K – 9.6 mmol/L

As hyperkalemia was confirmed, the patient was also given 200 ml of 25% dextrose with 12 units of Rapid-acting insulin IV. With the above measures, the patient’s cardiac rhythm came to a sine wave pattern. 

He was later taken up for emergency hemodialysis (HD) – Sustained Low Efficacy Dialysis (SLED) in the ICU, using a low potassium dialysate. Since his AV fistula was non-functioning, HD was done after placement of a femoral dialysis catheter. 2 hours into HD, the patient’s cardiac monitor showed a normal sinus rhythm. His hemodynamic status significantly improved. Noradrenaline infusion was gradually tapered and stopped by the end of the HD session, and repeat blood gas analysis and serum electrolytes showed improvement of all parameters. 

after hemodialysis

The patient was discharged 2 days later, after another session of hemodialysis (through AV fistula) and a detailed cardiology evaluation (ECHO – LVH, normal EF).

For the Inquisitive Minds

  1. The patient underwent a detailed POCUS evaluation, both in the ER and ICU. What findings do you expect to find on the RUSH examination for this patient?
  2. His previous ECHO report (done 1 month ago) mentioned left ventricular hypertrophy and normal ejection fraction. So what would be the reason behind the POCUS findings? Is it reversible?
  3. Why was the AV fistula non-functioning at the time of presentation? When would it have started to function again?
  4. Despite not having hypoxia, this patient was given supplemental oxygen. Did he really require it, and if so, what was the rationale?
  5. What was the necessity for carrying out SLED for this patient?
  6. Why was this patient not immediately cardioverted in the ER?
  7. If this patient had gone into cardiac arrest, what drugs would you have given for management of hyperkalemia?
  8. How differently would you have managed this patient?

Please give your answers and comments into "leave a reply" area below.

Cite this article as: Gayatri Lekshmi Madhavan, India, "From Missed Hemodialysis to Multiple Arrhythmias," in International Emergency Medicine Education Project, November 2, 2020,, date accessed: December 2, 2023

Question Of The Day #3

question of the day
question of the day 3

Which of the following is the most appropriate next step in management for this patient‘s condition?

Choice A (IV 1,000mL of 0.9% NaCl) is an isotonic crystalloid fluid helpful in a patient with depleted intravascular volume (i.e., dehydration). This patient is clinically dehydrated (dry oral mucosa and mild tachycardia); however, hypertonic 3% NaCl is a more appropriate initial treatment. Choice B (IV 50mL of 25g dextrose solution, or commonly known as “D50”) is an appropriate treatment for a patient with hypoglycemia. Checking a glucose level is a crucial part of the initial assessment of all patients with altered mental status, but this patient has a reported normal glucose level. Choice D (IV 40mg Furosemide) is a diuretic that would worsen this patient’s dehydration and acute kidney injury. This patient has severe hyponatremia along with neurological symptoms (coma and seizure). Hyponatremia plus neurologic symptoms, like vomiting, seizures, reduced consciousness, cardiorespiratory arrest, necessitate rapid correction of sodium with hypertonic (3%) NaCl solution. 3% NaCl solution can be infused 100-150mL over 15-20min and repeated up to 3 doses total. A serum sodium level should be measured after each administration of 3% NaCl in order to limit the increase in the sodium level to no more than 8-12 mEq/L over the first 24hours. This is done to reduce the risk of osmotic demyelination syndrome. Correct Answer: C


Petrino R, Marino R. Fluids and Electrolytes. “Chapter 17: Fluids and Electrolytes”. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th ed. McGraw-Hill.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #3," in International Emergency Medicine Education Project, July 8, 2020,, date accessed: December 2, 2023

Hyperkalemia Treatment – Infographic

hyperkalemia treatment

Further Reading

Weisberg LS. Management of severe hyperkalemia. Crit Care Med. 2008 Dec;36(12):3246-51. doi: 10.1097/CCM.0b013e31818f22b. Review. PubMed PMID: 18936701.

Cite this article as: Kaushila Thilakasiri, Sri Lanka, "Hyperkalemia Treatment – Infographic," in International Emergency Medicine Education Project, January 8, 2020,, date accessed: December 2, 2023

Clinical Video: abnormal hand twitching

Case Presentation

A 43-year-old female presented with altered mental status (GCS of 10/15) and abnormal twitching of hand. Reported to have a long-standing history of constipation and had been on laxatives. POC electrolytes showed Sodium: 110 mmol/L, Potassium: 3.5 mmol/L and Calcium: 0.71 mmol/L. The case managed as symptomatic euvolemic hyponatremia, hypocalcemia, and SIADHS.

Symptoms of hypocalcemia

Numbness and/or tingling of the hands, feet, or lips, muscle cramps, muscle spasms, seizures, facial twitching, muscle weakness, lightheadedness, and bradycardia.

Symptoms of hyponatremia

Nausea and vomiting, headache, confusion, loss of energy, drowsiness and fatigue, restlessness and irritability. muscle weakness, spasms or cramps, seizures, coma.

At the presentation time of the patient, you may not know these muscle spasms are because of hypocalcemia and hyponatremia’s similar symptoms. So, laboratory tests can clarify the diagnosis. However, in this case, both (Ca and Na) are low. So, you treat both. 

In addition

There are two findings related to hypocalcemia which worth to mention. Chvostek’s sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve. Trousseau’s sign is carpopedal spasm caused by inflating the blood pressure cuff to a level above systolic pressure for 3 minutes. This video shows both findings.

Do you need more free clinical images or videos for your exams or presentations? Please visit iEM clinical image and video archive in Flickr and YouTube!

Cite this article as: Masuma Ali Gulamhussein, "Clinical Video: abnormal hand twitching," in International Emergency Medicine Education Project, July 10, 2019,, date accessed: December 2, 2023

Hypoglycemia by Rok Petrovčič from Slovenia

Hypoglycemia chapter written by Rok Petrovcic from Slovenia is just uploaded to the Website!


A 75-year-old woman was brought to the emergency department by her relatives for “not being her usual self” for a day. She was on insulin therapy for her diabetes, but otherwise healthy.

On examination, she appeared confused and disoriented. Her vitals were as follow her rate 95/min, respiratory rate 18/min, blood pressure 141 over 85mmHg, T 37.7°C and SP O2 99% on room air. Given her past medical history, capillary blood glucose test was performed by the bedside. It was 2.6 mmol/L equal to 47 mg/dL, and hypoglycemia was diagnosed.

She was given a bolus dose of intravenous glucose and much to the relatives’ relief and amazement; she returned to her normal behavior within 5 minutes. The patient herself reported lower urinary tract symptoms with a low-grade fever for the last two days. In addition, blood investigation showed that her renal function had also deteriorated significantly since her last primary care visit while continuing on the same insulin regime. The patient was subsequently admitted to a general ward for further evaluation and management.

by Rok Petrovčič from Slovenia.

A new chapter from Shabana Walia

Thyroid Storm chapter written by Shabana Walia from USA is just uploaded to the Website!

38 - atrial fibrillation

A 68-year-old female with hypertension presented to the emergency department with worsening of lower extremity swelling for the last few months. She appeared to be confused over the last three days according to her husband. He also noted that she had a fever. She had intermittent chest discomfort and was feeling “anxious.” She was compliant with the prescribed antihypertensive (lisinopril and hydrochlorothiazide). She used no tobacco or illicit drug. She had a family history of hypertension and hyperthyroidism.

Her vitals at triage were as follows: BP 170 over 86mmHg, HR 136/min, RR 18/min, Temperature 40.2°C and SP O2 100% on room air. She appeared agitated and flushed, with bilateral exophthalmos and lid lag. Her thyroid was diffusely enlarged with bruit noted. Her pulse was irregularly irregular. She had pitting edema up to the mid-shin. Bilateral plantar reflexes were 3+. The rest of the physical examination was unremarkable.

Her blood test results were as follow:
Normal CBC and renal function.
Calcium: 11.5 mg/dL
Thyroid stimulating hormone (TSH) < 0.01 milli-international unit/L
Free T3: > 30 picogram/mL
Free T4: > 6 nanogram/dL
Troponin: 0.1
Pro-BNP: 3,000 picogram/mL

A diagnosis of hyperthyroidism was made, and she was evaluated for possible thyroid storm.

by Shabana Walia from USA.

A new chapter

Hyponatremia chapter written by Vigor Arva and Gregor Prosen from Slovenia is just uploaded to the Website!

Bohermeen Spring Half Marathon 2014

A 72-year-old man was brought to the emergency department by his daughter. She reported that he had nausea, vomiting, and confusion and had been unwell for the last few days. He had hypertension and heart failure for the previous ten years and was on ACE-inhibitor, beta-blocker and thiazide diuretic.

At triage, the patient’s vital signs were usual: blood pressure 110 over 70 mmHg, heart rate 95/min, respiratory 15/min, temperature 36.1°C and SpO2 100% on room air. He appeared lethargic and walked with an unsteady gait. He had no focal neurological deficit. He had a normal skin turgor and no edema. Postural BP revealed mild orthostatic hypotension. The lab results showed a serum sodium concentration of 115 mEq/L.

by Vigor Arva and Gregor Prosen.

A comprehensive chapter from Toh Hong Chuen

Hyperglycemia chapter written by Toh Hong Chuen from Singapore is just uploaded to the Website!

61 - Diabetic Foot - Subcutaneous air

A 58-year-old lady presented with right foot pain for 3 days, associated with high fever, lethargy, polyuria, and polydipsia. At triage, air hunger was noted. Her vital signs were: blood pressure 82 / 46 mmHg, heart rate 131/min, respiratory rate 28/min, Temperature 38.7 and SpO2 98%. She was brought to the resuscitation room for further management.

Clinically, she was dehydrated and confused with GCS 14. Her neck was supple, and lungs were clear. Crepitus was noted on the dorsum of the right foot. Point of care blood tests showed: capillary glucose 40 mmol/L, capillary ketone 7.2 mmol/L, pH 7.22, bicarbonate 8 mmol/L, pCO2 20 mmHg, sodium 130 mmol/L, chloride 95 mmol/L, potassium 5.5 mmol/L and lactate 6.9 mmol/L.

A diagnosis of septic shock secondary to gas gangrene complicated by diabetic ketoacidosis was made. She was aggressively resuscitated with fluid and started on I.V. insulin infusion. Potassium replacement was withheld as potassium was elevated. Urinary catheterization was performed for strict input-output monitoring. Broad-spectrum antibiotics and intramuscular tetanus toxoid were given. X-ray of right foot confirmed subcutaneous air.

The patient was sent directly to the theatre and underwent extensive debridement for the gas gangrene. She had an uneventful recovery and was discharged 1 week later.

by Toh Hong Chuen from Singapore.

Do you have 9 minutes 40 seconds?

Hypernatremia chapter written by Vigor Arva and Gregor Prosen from Slovenia is just uploaded to the Website!

Pink Salt ^w^

A 79-year-old man was brought to the emergency department (ED) by his wife. She complained that the patient had general weakness and was feeling ‘unwell’ for the last two days. He had a history of dementia, diabetes, renal failure, and hypertension. He was on diabetic and antihypertensive medication.

On examination, his vital signs were as follow HR 115/min, BP 135/90 mmHg, RR 17/min, and afebrile with normal oxygen saturation. He was confused and disoriented, but there was no other deficits or localizing signs on neurological exam. He was clinically dehydrated with dry oral mucosa. Lab results showed a serum sodium concentration of 160 mEq/L, with elevated glucose, creatinine, urea, and osmolality. Point of care ultrasound demonstrated a small and almost totally-collapsed inferior vena cava. Upon further history taking, the patient’s wife reported that he had not been drinking much for the last few days, even though he did not complain about thirst.

by Vigor Arva and Gregor Prosen from Slovenia