Clinical Communications: Adults
Tetraparesis and Failure of Pacemaker Capture Induced by Severe Hyperkalemia: Case Report and Systematic Review of Available Literature

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Abstract

Background

In severe hyperkalemia, neurologic symptoms are described more rarely than cardiac manifestations. We report a clinical case; present a systematic review of available literature on secondary hyperkalemic paralysis (SHP); and also discuss pathogenesis, clinical effects, and therapeutic options.

Case Report

A 75-year-old woman presented to the emergency department complaining of tetraparesis. Her serum potassium level was 11.4 mEq/L. Electrocardiogram (ECG) showed a pacemaker (PMK)-induced rhythm, with loss of atrial capture and wide QRS complexes. After emergency treatment to restore cell membrane potential threshold and lower serum potassium, neurologic and ECG signs completely disappeared. An acute myocardial infarction subsequently occurred, possibly linked to tachycardia induced by salbutamol therapy. We reviewed 99 articles (119 patients). Mean serum potassium was 8.8 mEq/L. In most cases, ECG showed the presence of tall T waves; loss of PMK atrial capture was documented in 5 patients. In 94 patients, flaccid paralysis was described and in 25, severe muscular weakness; in 65 patients, these findings were associated with other symptoms. Concurrent renal failure was often documented. The most frequent treatments were dialysis and infusion of insulin and glucose. Eighty-seven percent of patients had complete resolution of symptoms.

Why Should an Emergency Physician Be Aware of This?

Severe hyperkalemia is always a life-threatening medical emergency, as it can precipitate fatal dysrhythmias and paralysis. SHP should be considered in the differential diagnosis of neurologic signs and symptoms of uncertain etiology, especially in a subject with kidney failure or who is taking medications that may worsen renal function. The presence of a PMK does not necessarily impede hyperkalemic cardiac toxicity.

Introduction

Severe hyperkalemia is a well-known life-threatening event that can lead to fatal cardiac dysrhythmias or neurologic derangements, such as muscle weakness and paralysis. Paralysis related to high serum potassium levels may be a recurrent and predictable syndrome due to a genetic disease (familial periodic paralysis) or an isolated, acute, and often undiagnosed event; the latter condition is known as secondary hyperkalemic paralysis (SHP). In clinical practice, neurologic symptoms are rarely seen, perhaps because cardiac manifestations begin earlier and are more frequently thought of and managed. We report a case where a patient presented with the chief complaint of hyperkalemia-induced paralysis and subtle, though very serious, cardiac abnormalities. In addition, we present a systematic review of available literature, discussing this condition together with the cardiac and neurologic effects of hyperkalemia, as well as its pathogenesis and therapeutic options.

Section snippets

Case Report

A 75-year-old woman was sent to the emergency department by her general practitioner, who diagnosed “Transient ischemic attack. Drop attack. Patient unable to keep a standing position.” Her history revealed an acute myocardial infarction several years earlier, hypertension, sick sinus syndrome managed with a dual-chamber pacemaker (PMK), and mild chronic kidney disease. Her medications included acetylsalicylic acid (300 mg/d), benazepril (10 mg/d), amiloride/hydrochlorothiazide (5/50 mg/d),

Literature Review

We performed a systematic review of available medical literature on SHP using PubMed, Scopus, and EBSCO databases. After excluding all cases of familial periodic paralysis, we found 101 articles reporting cases of SHP. Two articles were not reviewed because they were written in Japanese and Polish 1, 2. Finally, we included 99 articles in our revision (the list is available as an online Supplementary Appendix). For one article (Teixeira, 2009; see Supplementary Appendix), the full text was not

Discussion

Although in the context of medical emergencies severe hyperkalemia is a rather common clinical condition, neurologic findings seem to occur much more rarely than cardiac symptoms, even if derived from similar pathophysiologic mechanisms. Based on Nernst equation, the ratio of extracellular to intracellular potassium concentration (Ke/Ki) determines the value of the resting membrane potential; when Ke increases, the difference in membrane potential decreases and, accordingly, the activation of

Why Should an Emergency Physician Be Aware of This?

SHP is a rare but potentially fatal clinical condition, the precise pathogenesis of which is unknown. High serum potassium levels may affect either muscle cell membrane or peripheral nerves. Even if mild chronic hyperkalemia can be an exception, high serum potassium levels should always be considered as a potentially life-threatening condition. The effects can be catastrophic, especially when the increase in serum potassium is acute, as a rapid increase may precipitate fatal dysrhythmias and

Acknowledgments

The authors thank Mrs. Daniela Fedele, Library of Medicine, University of Trieste, for her excellent support.

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