48: Numb Hands

A 32 year old male presents with 2 days of a pins and needles sensation in both hands. He states he fainted about 1 hour ago and hit his head. He denies chest pain or trouble breathing, or any symptoms in his legs or feet.

Physical exam is unremarkable except for a 2cm eyebrow laceration.

An EKG is shown below.

What findings should you search for in a patient who has fainted?

What findings on this EKG  might be important.

What if any other tests would you recommend?

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Answer: You should look for abnormal intervals such as a long QT or short PR.  You should look for abnormal ST segments which might signify a Brugada pattern or myocardial ischemia.  You should look for abnormal T-waves which could signify ischemia or an electrolyte abnormality.

In this EKG, there are peaked T-waves.  The EKG computer may miss T-wave changes, and read this EKG as “Benign Early Repolarization”.  The patient had severe hypekalemia with K+ = 8.4.  His baseline EKG is shown below.

MORE ON HYPERKALEMIA

from

QUICK ESSENTIALS: EMERGENCY MEDICINE Version 4.0

Symptoms:  Fatigue, muscle weakness, hand paresthesias, palpitations.  Often asymptomatic
EKG:    First confirm with an EKG: peaked T, early repol > long PR, brady > RBBB, wide QRS
Rx by level: >5.5: Kayexylate 30g, Lasix.      >6: Telemetry, albuterol.     >6.5: D50 + insulin, bicarb.

TREATMENT:    Calcium     Bicarb.    Albuterol    Insulin/glucose    Kayexylate
INDICATION:    Wide QRS         Acidotic    K > 6    K > 6    K > 5.5
MECHANISM:    Cardioprotects    Shift    Shift    Shift    Elimination
DOSING:    1amp over 3m    1-3 amps    10mg     5u R per amp D50    30 grams
ONSET:    1-2min    5-10min    15min    30min    1-2hours
SIDE EFFECTS: Digoxin?    Alkalosis    Tachycardia    Hypoglycemia    CHF

DURATION:    30-60min    1-2hours    1hour    4-6hours    4-6hours

*  Insulin:    Give only 5 units or none if severe renal or liver disease.  Don’t need any if not diabetic
Causes:    “BAD STAR”: BB, ACEI, Aldactone, Dig, Sulfa, TPN, Addison, Acid, Renal, Rhabdo
more meds:Cyclosporin, heparin, NSAID, tacrolimus…(See A to Z Pocket Pharmacopoeia for more)

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