Hyperkalemia and severe rhabdomyolysis

A 47-year-old homeless man with a history of bipolar disorder and polysubstance abuse was found under a bridge with altered mental status and severe left calf pain. Evaluation in the emergency department revealed a cachectic, pale man with a blood pressure of 132/84, pulse 74, and respirations 18. He was afebrile. Oxygen saturation was 98% on room air. Examination revealed marked swelling of the left leg, which was also pulseless. A compartment syndrome was diagnosed. Urgent fasciotomy was performed, and the patient was treated in the critical care unit. After a long hospital course he was discharged after 22 days. The initial electrocardiogram (ECG) (Fig. 1) revealed tall, peaked T waves (greater than 10 mm) and a QRS duration of 100 msec. Creatine phosphokinase (CK) initially was 67,762 units/L and increased to 149,440 units/L, indicative of severe rhabdomyolysis. Creatinine increased to 11, and emergency hemodialysis was undertaken. CK eventually dropped to normal after 14 days. The electrocardiographic changes were typical of hyperkalemia, and the initial potassium was 8.0. A follow-up tracing taken soon after the administration of calcium chloride, sodium bicarbonate, and sodium polystyrene sulfonate showed narrowing of the QRS duration to 80 msec, and the T waves were not as peaked but were still prominent. (Fig. 2) Potassium had dropped to 5.9 by that time. Potassium decreased further to