Hyperkalemia of 10.1 mmol/L without Electrocardiographic Abnormalities in a Patient with Rhabdomyolysis: A Case Report

doi:10.21203/rs.3.rs-5100515/v1

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Case Report

Hyperkalemia of 10.1 mmol/L without Electrocardiographic Abnormalities in a Patient with Rhabdomyolysis: A Case Report

https://doi.org/10.21203/rs.3.rs-5100515/v1

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Introduction

Hyperkalemia is a life-threatening condition that can lead to electrocardiographic changes and cardiac arrest; to prevent and treat hyperkalemia, it is necessary to understand the underlying causes and correctly interpret the symptoms. The four most common causes of hyperkalemia are renal dysfunction, drugs that alter potassium secretion in the distal tubule, high dietary intake of potassium and increased potassium release from cells; on trauma patients the rhabdomyolysis is a leading cause of hyperkalemia.

Case presentation

This case involves a 36-year-old male patient who suffered severe trauma from a high-speed vehicle accident, resulting in multiple injuries and a Glasgow Coma Scale score of 3/15. Initial assessment revealed critical airway compromise and significant hemodynamic instability. Laboratory tests indicated extreme hyperkalemia with a serum potassium level of 10.1 mmol/L and elevated creatine kinase (CK) levels, leading to a diagnosis of rhabdomyolysis. Notably, the patient exhibited no electrocardiographic changes typically associated with hyperkalemia. Emergency interventions included intubation, fluid resuscitation, and urgent hemodialysis, which successfully normalized potassium and CK levels over time.

Conclusions

This report emphasizes the importance of prompt recognition and management of hyperkalemia in trauma patients, highlighting a multidisciplinary approach to prevent severe complications and improve patient outcomes.

Hyperkalemia

Rhabdomyolysis

ECG changes

Acute kidney injury

Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mmol/L and is a life-threatening condition that can lead to cardiac arrest, with a mortality rate of up to 41% in hospitalized patients; the classification of the severity of hyperkalemia depends on the plasma potassium concentration and electrocardiographic changes (5.9 mmol/L with no EKG changes to severe with a potassium value greater than 6.5 mmol/L with EKG changes) [1–3].

To prevent and treat hyperkalemia, it is necessary to understand the underlying causes and correctly interpret the symptoms. The four most common causes of hyperkalemia are renal dysfunction, drugs that alter potassium secretion in the distal tubule, increased potassium release from cells, and high dietary intake of potassium [1, 3].

Altered cardiomyocyte excitability, which is the main cause of increased mortality in hyperkalemia, is diagnosed by electrocardiogram (ECG). The sequence of electrocardiographic findings consists of peaked T waves, prolonged PR intervals, and progressive widening of the QRS complex, followed by sinusoidal wave patterns, ventricular fibrillation and asystole. The most frequent findings are peaked T waves followed by prolongation of the QRS complex [1]

Emergency treatment of hyperkalemia is mainly based on the initiation of dialysis. The pharmacological approach to the treatment of hyperkalemia is to stimulate cellular potassium uptake and urinary potassium excretion [3, 4]

Rhabdomyolysis (RML) is a life-threatening condition caused by acute kidney injury (AKI), which results in increased serum creatinine, myoglobinuria and low urinary flow syndrome. Pathophysiological explanations include tubular obstruction by myoglobin and ischemic tubular injury, which are important aspects of the complex mechanism of AKI related to MRL [2]. One cause is physical/traumatic causes such as polytrauma, prolonged immobilization, torture, fractures, high-voltage electric shock and lightning, and strenuous muscle exercise [2, 3].

Treatment prioritizes adequate fluid resuscitation and prevents acute kidney injury [4, 5].

On March 6, 2023, a 36-year-old male was brought to the emergency department following a high-speed road accident. Prehospital emergency medical services assessed him and found him unconsciously, lying in a prone position, with a Glasgow Coma Scale score of 3/15. His skin appeared pale and cold, with cyanosis noted in the distal extremities and central diaphoresis. Examination revealed a 3 cm laceration in the right parietal region, a 2 cm lesion with irregular edges in the left supraciliary area, and an abrasion on the left anterior iliac crest in the pelvic region. The patient exhibited pelvic instability, deformity, and swelling in the middle third of the left thigh, as well as deformity and abrasion in the left forearm. Vital signs indicated hypotension with a blood pressure of 80/60 mmHg, bradycardia with a heart rate of 63 beats per minute, and tachypnea with a respiratory rate of 24 breaths per minute; oxygen saturation was 92%. Owing to the patient's deteriorating level of consciousness, a rapid intubation sequence was initiated to secure the airway, and analgesic management with buprenorphine was provided.

Abdominal, thoracic, and cranial tomography was performed (Fig. 1 and Fig. 2), revealing a perimesencephalic hematoma; multiple pelvic and left femur fractures, including left ischiopubic, left acetabular, and left distal epiphyseal radii and ulna; a left distal epiphyseal femur; a left fibula; a T2-T3 fracture; 10th and 11th left costal arches; left diaphragmatic rupture with partial gastric herniation into the thoracic cavity; and a right pneumothorax.

Surgical, orthopedic, and trauma services were consulted, leading to open reduction with internal fixation of the left femur. Following the procedure, the patient was admitted to the intensive care unit (ICU) for postsurgical management.

On March 7, 2023, the patient was admitted to the intensive care unit (ICU) under mechanical ventilation; furthermore, laboratory tests and arterial blood gas tests were ordered (Table 1 and Table 2).

Table 1

Laboratory results, arterial blood gases, obtained on 07.03.2023
Test	Result	Normal Reference Range
pH	7.42	7.35–7.45
PCO2 (mmHg)	37.4	35–45 mmHg
PO2 (mmHg)	123.5	75–100 mmHg
Lactate (mmol/L)	4.7	0.5–2.2 mmol/L
HCO3 (mEq/L)	24.6	22–26 mEq/L
PO2/FiO2 Ratio	205.9	> 300 (normal)

Table 2

Laboratory results obtained on 07.03.2023
Test	Result	Normal Reference Values
Hemoglobin	6.5 g/dL	13.5–17.5 g/dL (men) 12.0-15.5 g/dL (women)
Hematocrit	26.2 mg/dL	38.3%-48.6% (men) 35.5%-44.9% (women)
Leukocytes	8,602 x10⁹/L	4,500 − 11,000 x10⁹/L
Neutrophils	80.2%	40%-70%
Platelets	237,000	150,000-450,000
Sodium	148 mEq/L	135–145 mEq/L
Potassium	10.1 mEq/L	3.5–5.1 mEq/L
Chloride	113 mEq/L	98–107 mEq/L
Magnesium	1.1 mEq/L	1.7–2.2 mEq/L
Creatinine	8.2 mg/dL	0.7–1.3 mg/dL (men) 0.6–1.1 mg/dL (women)
Creatine Kinase	10,200 IU/L	30–200 IU/L

High CK levels and the presence of hyperkalemia led to the diagnosis of rhabdomyolysis.

In addition, this was due to posttraumatic diaphragmatic rupture. A diaphragmatic plasty was performed.

Vertebral Fracture of T1 and T2 associated with Anterolisthesis

Calcium gluconate and insulin dextrose were administered to control hyperkalemia. Otherwise, no abnormalities were demonstrated on the electrocardiogram image (Fig. 3). Acidosis was corrected by infusion of 8.4% sodium bicarbonate. The intravenous administration of furosemide was started. Owing to his elevated serum creatinine, severe metabolic acidosis and hyperkalemia, urgent hemodialysis via a Mahurkar catheter was performed. The creatinine value and CK level were monitored daily. Four consecutive hemodialysis sessions were performed every two days and then daily since we lacked the supplies for continuous renal replacement therapy (PRISMA FLEX). Gradual improvement in urine output was observed, and her CK levels normalized after 10 days of renal replacement therapy.

The patient was discharged from the ICU to the traumatology service for referral to the third level for fracture of the thoracic vertebrae.

The case involves a 36-year-old male patient who was brought to the hospital after being run over a high-speed road.

Upon evaluation of the patient’s general condition, airway compromise, respiratory distress, decreased peripheral perfusion and signs of hemodynamic instability were detected. Resuscitative measures were initiated. Clinical and laboratory tests led to the diagnosis of rhabdomyolysis, with hyperkalemia of 10.1 mmol/L without electrocardiogram findings indicating conduction compromise.

A similar case was reported in India by Dahal et al [6], who reported a 55-year-old male patient with findings of a Brugada pattern on an electrocardiogram secondary to hyperkalemia due to rhabdomyolysis due to trauma; however, the serum level of this patient was 7.3 mEq/L. Ittyachense et al [7] reported a case of an 84-year-old male with a history of diabetes mellitus, hypertension and probable chronic kidney disease with a history of significant potassium-sparing diuretic use and excessive consumption of bananas whose serum potassium value was 10.4 mEq/L, with electrocardiographic findings of an absent P wave and widening QRS complex.

In the case reported by Haykal et al. [8] of a 69-year-old female with a history of type 2 diabetes mellitus, hyperlipidemia, NYHA Class II heart failure and stage 3 CKD, an electrocardiographic study revealed no significant changes despite a serum potassium level of 8.3 mEq/L.

Most cases of hyperkalemia with electrocardiographic findings are in elderly patients with medication and comorbidities that lead to a potassium-sparing state (diabetes mellitus, use of spironolactone, or some stage of chronic renal disease); acute cases of hyperkalemia secondary to rhabdomyolysis are not frequent; therefore, we present an unusual case without electrocardiographic manifestations.

The present case highlights the importance of recognizing and addressing hyperkalemia, a medical condition that can trigger serious and even fatal cardiovascular complications, in a timely manner. The patient presented with high-impact trauma with multiple fractures and internal injuries, which contributed to the development of hyperkalemia.

This case underscores the importance of a multidisciplinary approach and comprehensive medical care in the management of trauma-induced hyperkalemia, highlighting the need for proper evaluation and treatment to prevent potentially fatal complications and improve patient prognosis.

Funding

This study was not supported by any sponsor or funder

Conflicts of interest/Competing interests

The authors declare no competing interests.

Ethics approval

Not applicable.

Consent to participate

Written consent to participate was obtained from the patient

Written Consent for publication

Written consent for publication was obtained from the patient

Availability of data and material

Not applicable

Code availability (software application or custom code)

Not applicable

Authors' contributions

L.E.M.R., J.A.D.L. and B.O.D.S. wrote the manuscript text and made substantial contributions to the conception or design of the work also drafted the work or revised it critically for important intellectual content; approved the version to be published; and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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Oliveira MABD, Brandi AC, Santos CAD, Botelho PHH, Cortez JLL, Braile DM (2014) Modes of induced cardiac arrest: hyperkalemia and hypocalcemia - literature review. Revista Brasileira de Cirurgia Cardiovascular. https://doi.org/10.5935/1678-9741.20140074
Hoppe LK, Muhlack DC, Koenig W, Carr PR, Brenner H, Schöttker B (2018) Association of Abnormal Serum Potassium Levels with Arrhythmias and Cardiovascular Mortality: a Systematic Review and Meta-Analysis of Observational Studies. Cardiovasc Drugs Ther 32:197–212
Te Dorsthorst RPM, Hendrikse J, Vervoorn MT, Van Weperen VYH, Van Der Heyden MAG (2019) Review of case reports on hyperkalemia induced by dietary intake: not restricted to chronic kidney disease patients. Eur J Clin Nutr 73:38–45
Dahal K, Shrestha D, Hada R, Baral A, Sherpa K (2020) Hyperkalemia mimicking brugada pattern in electrocardiogram: A rare case report from Nepal. Saudi J Kidney Dis Transpl 31:524
Ittyachen AM, Sukumaran A, Peter A, Baby B, Anthony D (2024) Hyperkalemia in the tropics: multiple causes and a not so common presentation—a case report. Egypt J Intern Med 36:12
Haykal R, Youniss MA, Kateb MA, Toklu HZ, Bray CL (2018) A Case of Severe Hyperkalemia Presenting with No Significant ECG Changes. JCDR. https://doi.org/10.7860/JCDR/2018/32388.11520

No competing interests reported.

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Hyperkalemia of 10.1 mmol/L without Electrocardiographic Abnormalities in a Patient with Rhabdomyolysis: A Case Report

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Version 1

Abstract

Figures

Introduction

Case Presentation

Vertebral Fracture of T1 and T2 associated with Anterolisthesis

Discussion

Conclusions

Declarations

References

Additional Declarations

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