Published 03/08/2022





Single peripheral cannula, left radial arterial line 






Present in bedspace but switched off 


ECG consistent with hyperkalaemia 

ABG consistent with hyperkalaemia 

Clinical Setting

I:       You are the HDU registrar called to assist the HDU resident 

S:      He/she is concerned about new admission, a 66-year-old man with ESRF who has just undergone a fistula revision, 1 PVC and radial arterial line in situ 

B:      ESRF secondary to diabetes, recent cellulitis and fistula fail, usually on ACEi 

A:     Drowsy, responds to pain 

R:      Called you for assistance 

Potential Clinical Course

  • Initially A gurgling, B RR 32, SpO2 89% on RA, coarse crackles bilaterally, C HR 100, BP 95/40, CRT 5 sec, D responds to pain, E fistula has a weak thrill 
  • Abnormal ECG consistent with hyperkalaemia 
  • Patient collapses into pulseless VT 
  • Progresses down ALS algorithm 
  • Continues until relevant reversible causes considered 
  • Blood gas if requested - K+ 7.4 (venous or arterial) 
  • ECG from admission to unit consistent with hyperkalaemia, consider calcium chloride 
  • VT reverts to SR after defibrillation 
  • Inadequate respiratory effort 
  • Declares need for intubation and ventilation 

Information for Faculty

  • Initial Settings (only visible once monitor attached): 
    • RR 32 
    • O2 Sats 89% on air 
    • Coarse crackles bilaterally to lung fields 
    • HR 100bpm – tall tented T waves on monitor 
    • BP 95/54 


  • Progress to pulseless VT 


  • Successful DC cardioversion only after administration of calcium chloride 


  • Post DC Cardioversion: 
    • No respiratory effort
    • O2 Sats 85% on 100% via BVM 
    • BP 145/88 
    • HR 118bpm SR 
    • Coarse crackles throughout lung fields 

Faculty Roles

Bedside Nurse: 

  • You are a CNS 
  • You have just received the patient from theatre recovery with little handover, except the preadmission letter and anaesthetic chart 
  • You haven’t yet had time to attach the monitor – you are setting up a Hudson mask and oxygen tubing as routine 
  • Do not attach any monitoring unless asked to do so – instead task yourself with documentation/looking for other equipment 


HDU Resident: 

  • You have just started you HDU term 
  • You know that the patient is 66 years old, has had an operation on a fistula, and is normally on dialysis – you note he is a “little drowsy” but you’re sure that it’s probably an effect of the anaesthetic as he has been to theatre 
  • You take direction very well, but offer little 


HiLLO: 5, 7