Podcast 1015: Calcium in Hyperkalemia

这里是急诊医学一分钟，由CarePoint和HCA HealthONE赞助。

This is the emergency medical minute sponsored by CarePoint and HCA HealthONE.

好的。

Okay.

那么，关于高钾血症，我不知道最近有没有人讲过这个话题。

So hyperkalemia, this is probably I don't know if anybody's done this topic recently.

可能有人讲过，因为这是一项刚出来的新研究。

They may have because this is a new study that just came out.

我们可能会很兴奋，讨论几个月，然后就不再提了。

We'll probably get really excited about it and talk about it for a couple of months and then never talk about it again.

但高钾血症，就是血钾水平过高的情况。

But hyperkalemia, we have so people who have too high of a level of potassium.

钾是致命注射的关键成分，对吧？

Potassium is the workhorse of a lethal injection, right?

所以，如果钾太高，即使没有其他问题，也足以让心脏停跳。

So like your potassium getting too high, if it's nothing other than potassium, is enough to make your heart stop.

所以这是一种非常危险的电解质，一旦失衡就很麻烦。

So it's a very dangerous electrolyte when it gets out of whack.

它由肾脏过滤，主要通过肾脏排出。

It's filtered by the kidneys and excreted mostly by the kidneys.

所以肾衰竭的患者最终可能会出现高钾血症。

And so people in kidney failure can end up with hyperkalemia.

还有其他几种情况也可能导致高钾血症。

There's a couple other ways you can end up with hyperkalemia.

但大多数时候，还是肾脏问题引起的。

Most of the time, it's kidney problems though.

当有人因血钾过高而危急时，我们需要做三件事。

Three things we have to do when somebody comes in with a critically high potassium.

在这些措施中，钙剂排在哪个位置？

Where in that list of things does calcium fall?

我们排在第二梯队。

We're in the second tier.

是在第一步。

It's in the first.

我们先做这个。

We do it first.

我们给钙，背后的想法一直是，我们给它是为了

We give it and the thought behind it was always that we were giving it

为了

for

稳定细胞膜。

membrane stabilization.

我们总是这么说。

We say that all the time.

所以，比如在住院医师培训期间，当你去查房，做类似这样的事情时，主治医生会坐在小组前面，病人也在那里，还有一群护士，她们肯定比任何住院医生都更懂医学。

So, like, in residency, when you are going on rounds and sort of doing, like, things like this, the attending will sit at the front of the little group and the patients there and a bunch of nurses that for sure know a lot more about medicine than any of the residents do are there.

这很尴尬，主治医生会轮流问每个人问题，看看你对某个话题了解多少。

And it's very embarrassing, the attending will go around and start asking everybody questions to be like, how much do you know about a topic?

而且目标不是要赢。

And the goal is not to win.

目标不是比主治医生懂得更多。

The goal is not to know more about it than the attending does.

目标是能撑过几轮，撑得体面一点。

The goal is to to last a respectable number of rounds.

所以这叫做“查房技巧”。

And so it's called roundsmanship.

特拉维斯·巴洛克在这方面很擅长。

Travis Barlock is very good at this.

就像你可以坐在那儿，和他你来我往地聊医学话题，直到其中一个人没话说了。

It's like you can sit there and just banter with him back and forth about medical things until one of you runs out of things to say.

所以高钾血症，因为它有一套固定的处理流程，我们在查房时经常讨论，因为你可以按步骤来谈怎么治疗。

So hyperkalemia, because it's like such a regimented thing, is something that we would talk about on rounds a lot because you can kind of go through the stepwise fashion of how you treat it.

钙是我们首先给的。

Calcium is the first thing that we give.

钙有两种形式。

There's two forms of calcium.

一种是葡萄糖酸钙，另一种是氯化钙。

We have calcium gluconate and calcium chloride.

葡萄糖酸钙的分子比较大。

Calcium gluconate gluconate's kind of like a big molecule.

你可以把它想象成一个大分子，里面含有少量的钙。

You can think of it like this big molecule and little bits of calcium are sort of in there with it.

注射它的时候，不太会引起静脉硬化之类的问题。

And when you give it, it doesn't tend to, like, sclerose the veins or anything like that.

它的浓度可能稍微低一点。

It's maybe a little bit less concentrated.

注射时间会稍微长一些。

It takes a little bit longer to give.

氯化钙是我们急救车里的那种。

Calcium chloride is what we have in the code card.

所以，比如快不行的人就会用氯化钙。

So, like, people who are dying get calcium chloride.

所以，你知道，如果来的人情况真的很不稳定，你开始看到高钾血症在心电图上的影响了。

And so the you know, if this is somebody who comes in and they're truly unstable, you're starting to see the effects of the hyperkalemia on their EKG.

很多时候，尽管它会刺激血管，你还是想要一个大号的静脉通道，但那些人用的是氯化钙。

A lot of times, even though it's sclerosing, you want a big IV, but those people are getting calcium chloride.

如果你有葡萄糖酸钙，那也可以。

If you have calcium gluconate, that's fine as well.

当时的想法是它能稳定心肌细胞膜。

The thought was that it stabilized the cardiac membrane.

当我们给氯化钙的时候，基本上当钾离子变得非常高的时候，你可以看到人的心电图开始变宽。

When we give calcium chloride, basically potassium as it gets to be really, really high, you can watch people's EKGs start to widen out.

他们的QRS波群开始变宽。

Their QRS complexes start to widen out.

最后，这会变成那种非常吓人的正弦波。

And eventually, that turns into this very scary sine wave.

如果不及时处理，病人最终会心脏骤停。

And if that's not treated at some point, they get the patient will go into cardiac arrest.

你给的钙，其实可以在心电图或心律监测条上看到效果。

The calcium that you give, you can actually watch it on the EKG or on the rhythm strip.

它会让QRS波群开始变窄，恢复正常。

It will start to narrow their QRS complexes back to normal.

所以这个起效很快。

And so it is quick.

但持续时间不长。

It doesn't last for very long.

它大概能给你争取三十分钟，让你有时间去处理高钾血症的其他措施。

It buys you about thirty minutes to start doing everything else you have to do in in hyperkalemia.

接下来要做的是把钙重新弄回细胞里。

The next set of things that you're doing is trying to force calcium back into cells.

当我们给……抱歉。

When we give sorry.

把钾推回细胞内。

Force potassium back into cells.

当我们给钙的时候，我们看到心电图开始好转。

When we give calcium, we're we're watching that EKG start to look better.

但如果你去测病人的血钾，和给钙之前没什么两样。

But if you were to test the patient's potassium, it's no different than before you gave the calcium.

所以血钾还是高的。

So it's still high.

接下来你可以做的，而且可以很快见效的，就是开始把钾转移到细胞内。

The next thing you can do, which can happen fairly quickly, is start to shift potassium into cells.

我们有好几种方法来做这件事。

And so we do that a handful of ways.

最常用的方法是用胰岛素和D50。

The most popular way to do it is with insulin and d fifty.

我们通常喜欢静脉推注5单位胰岛素，因为剂量低的话，在肾功能有问题的人体内停留的时间会更长。

We typically like to give five units of insulin IV because the lower dose hangs around a lot longer when people have renal problems.

他们的胰岛素排泄可能不如正常情况下那么顺畅。

They're not gonna be excreting their insulin as well as they otherwise might.

所以胰岛素容易在体内停留较长时间。

So that insulin tends to hang around.

根据他们的血糖水平，我们可能会给一些葡萄糖、少量葡萄糖，或者不给葡萄糖，但这要看他们的化验结果。

Based on what their glucose level is, we either give some glucose, a little bit of glucose, or no glucose, but, you know, that that's kinda based on what their labs.

所以我们需要一点时间来决定具体怎么做。

So we we need a little bit of time to sort of decide what that's gonna look like.

一旦我们做了这些，如果患者酸中毒很严重，还可以给碳酸氢钠，这也能帮助改善心电图表现。

Once we've done so other shifting things you can give bicarbonate if the patient's very acidotic can also help their EKG look a little bit better.

可以给沙丁胺醇。

You can give albuterol.

在新冠疫情期间，我们很多时候不用沙丁胺醇了，至少在我工作的地方是这样。

A lot of times in COVID era, we stopped doing albuterol cause at least where I was working.

如果患者需要戴口罩或使用吸入性药物，他们必须待在隔离病房，这在疫情期间非常不方便。

If you wanted them on a mask or on a respiratory inhaled medication, they needed to be in an isolation room, which was very inconvenient during COVID times.

现在我们已经没有那个问题了，我觉得重新开始使用一些沙丁胺醇应该没问题。

Now that we don't have that anymore, think it's probably fine to start bringing back some of the albuterol.

你需要非常高剂量的沙丁胺醇，所以我们通常给的那种小包装，我想大概是三包。

You want a very high dose of albuterol, so the little packets that we tend to give I think is like three.

你需要十到十五包。

You want like ten to fifteen.

所以那会很多包，可能会引起一些电解质转移。

So like it's a it's a lot of packets, it can give you some shifting.

接下来你要尝试的是排出体内的钾，也就是真正把钾从身体里排出去。

The next thing you wanna try and do is excrete, you know, actually get rid of the potassium out of the body.

我们有三种方法，最好的显然是透析，如果这些病人情况稳定，并且床边有人能帮你做透析，那显然是最好的选择。

And the three ways that we do that, the best one obviously is dialysis if these patients are stable enough, you have somebody at the bedside that can help you with dialysis, that's obviously the best thing.

很多时候，如果这些病人是晚上来的，我们就没有这个条件。

A of times if these patients are coming in overnight, don't have that ability.

所以其他排出钾的方法，你可以通过尿液排出。

So the other ways to excrete it, you can excrete it in your urine.

所以如果病人还在排尿，那可能是我们在急诊科能做的最快、最有效的方法，就是给一大剂量的速尿，让病人通过排尿排出一些钾。

So the patients are actually still making urine, that's probably like the fastest, effective thing we can do here in the emergency department is just give a big dose of Lasix and have the patients actually start excreting some of the potassium that way.

慢得多，也麻烦得多，但同样有效，你可以让他们通过排便排出来。

Much slower, much messier, but still effective, you can make them poop it out.

这就是用泻药的目的。

So that's what the local is for.

基本上，有很多研究尝试通过胃肠道，也就是肠道利尿来排出钾。

Basically, there's and there's been a bunch of things that have been studied in order to get GI kind of like gut diuresis of the potassium.

基本上，任何增加肠道排出的方法都有效。

And basically, anything that increases GI output will do it.

所以如果你让一个人拉很多，就能让他们排出钾。

So if you make someone poop a lot, you can make them excrete their potassium.

低钙镁要大约24小时才能真正起效。

It takes about twenty four hours for low calmo to really work.

所以我们在急诊科开这个药，它不是首先要做的事情。

So we if we order it in the emergency department, it is not the first thing that needs to be done.

我想关于钙，要记住的重要一点是，你可能需要重复给药，因为这是我们开始讨论这个话题的起因。

I would say the important thing to remember about calcium since that's kinda how we started on this is that you may have to redose it.

所以如果你在给病人用所有这些药，而胰岛素或速尿需要一段时间才能用上，你要知道钙的效果不是永久的。

So if you're giving somebody all of these medications and it takes you a while to get the insulin or it takes you a little bit of time to get the Lasix, you don't that that calcium doesn't just work for forever.

它的作用时间很短，你知道的。

It's a very short, you know, period of time.

它的目的是为你争取时间，所以如果你还在等其他措施到位，你可能需要重复给药。

It's meant to buy you some time and so you may have to redose it if you're still waiting on some of your other pieces to fall into place.

最后一点，也是我们提到这个的原因，他们刚刚在犬心肌细胞上做了研究，看看钾是否真的能稳定细胞膜。

The last thing, the reason that this came up, they just did this study in canine myocytes to see does does potassium actually stabilize the membrane?

它是否真的像我们一直说的那样起作用？

Does it act like does it actually do the thing that we've always said that it does?

结果并非如此。

And it does not.

显然，它是通过另一种机制起作用的，即通过心脏中的钙通道。

Apparently, it works through another mechanism where it works through calcium channels in the heart.

它仍然能发挥我们想要的所有作用。

It still does all of the things we want it to do.

它仍然能让那条难看的正弦波重新看起来像正常的心电图。

It still makes that ugly sine wave start to look like a normal EKG again.

所以我们还是会用它，但这一刻它很吸引人，因为我们多年来在查房时一直问，钙有什么作用？

So we still give it, but it is sexy for the moment because we've realized when we sit on rounds for years and years and years and say, what does calcium do?

然后有人说，它能稳定心肌细胞膜。

And someone says, it stabilizes the cardiac membrane.

嗯，那听起来确实很专业、很聪明。

Well, that sounds really sexy and smart.

但实际上并不是这样起作用的。

It's actually not how it works.

这里是急诊医学一分钟。

This has been the emergency medical minute.

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