Thoughts on this EKG?

[Gurby]

Sorry about the crummy quality. Patient basically has no complaints. Weighs ~300 pounds (which probably accounts for the low voltage).

 

[Burritomedic1127]

No STEMI, prob some electrolyte imbalance. Hyperkalemia?

 

[9D4]

I agree with possible hyperkalemia. Nothing else is really jumping out besides the t waves.

 

[Gurby]

Yep, he had a K of ~8!

The main thing that is catching me up is the rS complexes that extend all the way across - can anybody speak to those? Maybe part of it is poor lead placement, but it's still kind of puzzling to me. They aren't quite sine waves that you see in late hyperK, and they aren't QS so not indicative of an old MI or anything like that. I've seen an identical pattern in a handful of other hyperK ekg's on Google, but I can't figure out why it happens.

Does this guy's EKG look normal once you fix his K? Or are those rS complexes due to his anatomy and not the hyperK - I know in obese patients the heart can sometimes shift so it's laying more horizontally?

Would you call the axis indeterminate on this? Or would you say I is the isoelectric lead and call it a -80 degree extreme left deviation?

 

[teedubbyaw]

Peaked and fairly symmetrical T waves. Though, I don't trust this EKG since the quality is pure crap. His HR is a bit on the slow side for someone of that size.

 

[teedubbyaw]

Yep, he had a K of ~8!

The main thing that is catching me up is the rS complexes that extend all the way across - can anybody speak to those? Maybe part of it is poor lead placement, but it's still kind of puzzling to me. They aren't quite sine waves that you see in late hyperK, and they aren't QS so not indicative of an old MI or anything like that. I've seen an identical pattern in a handful of other hyperK ekg's on Google, but I can't figure out why it happens.

Does this guy's EKG look normal once you fix his K? Or are those rS complexes due to his anatomy and not the hyperK - I know in obese patients the heart can sometimes shift so it's laying more horizontally?

Would you call the axis indeterminate on this? Or would you say I is the isoelectric lead and call it a -80 degree extreme left deviation?

Things start to widen out and slow down with hyperkalemia. It should return to normal limits if he doesn't have any preexisting cardiac issues. Beyond that, call @Christopher @Brandon O @Remi

 

[Gurby]

Peaked and fairly symmetrical T waves. Though, I don't trust this EKG since the quality is pure crap. His HR is a bit on the slow side for someone of that size.

This was taken on a Zoll E-series, and every EKG looked like this (like crap). Is there a setting I need to play with, or is this just how EKGs look when you take them in the back of a running truck (vibration artifact?) as opposed to a hospital bed?

Also, he's in a rate controlled coarse AFib? Either that or it's a WAP and a bunch of artifact... Impossible to tell, I suppose.

 

[Brandon O]

Absolutely not typical for hyperkalemia. QRS/T complex should be much more wide and bizarre to match the other features. Is one/both of these post-treatment of some kind?

Very interesting strips. Can you share more about the presentation, medical history, meds, etc?

 

[Gurby]

Absolutely not typical for hyperkalemia. QRS/T complex should be much more wide and bizarre to match the other features. Is one/both of these post-treatment of some kind?

Very interesting strips. Can you share more about the presentation, medical history, meds, etc?

Dispatched for the "chest pain", on arrival find 60m with CC of peripheral numbness and headache that he developed 1 hour ago (which resolved on its own PTA). He says his AFib has been acting up for the past week. He had some sort of kidney surgery about a month ago (there's a clue... wish I could remember what it was), but is not on dialysis. By the time we get there, he basically has no complaints and is feeling fine, wants to walk to ambulance. We didn't do anything but transport, so no treatment from us. Later on in the shift I found out they transferred him out ALS to an ICU at a bigger hospital.

I'm blanking on the rest of the story... I think he was on an ACE inhibitor, metoprolol, might have been diabetic? You don't really get to be 60 years old and 300 pounds without some medical issues, but I do remember his med list was impressively short with only ~6 things on it. At the time I was thinking more about a possible TIA than electrolyte/kidney problems, and the EKG didn't jump out at me as being a huge/acute issue.

The strips are from about the same time. I readjusted leads after the 1st one because I wasn't happy with it, 2nd one was a tiny bit better.


I showed the strips to a friend who is an EM resident and she said the same thing as you... T waves are pathological (peaked, amplitude, symmetrical) but these are certainly not sine waves and it's pretty atypical.

 

[Gurby]

We know he has some Hx of kidney issues - it's certainly possible he took some med prior to arrival that's affecting the way he's presenting? I'm not sure what it would be or what it would do... And I suppose I wouldn't remember it from the list because I wouldn't have recognized it.

 

[teedubbyaw]

Possible hyponatremia, but I wouldn't expect EKG changes like that.

 

[Ewok Jerky]

So, basically we don't know his medical hx...

Peaked t waves are reminiscent of hyperK, and possible kidney disease. I agree with brandon though I would expect wider qrs complexes. also, this ekg is pretty poor quality, as is the rest of the scenerio

 

[Brandon O]

Here's what I've got, I guess...

The strip DOES look like A-fib. It DOES look like early hyperkalemia changes, such as peaked but not enlarged T waves. The loss of P waves is probably more attributable to the atrial fibrillation. The QRS/T certainly widened somewhat, but perhaps there's a baseline incomplete LBBB here as well.

It does NOT look like severe hyperkalemia. ECG changes aren't predictably associated with serum K, but you'd certainly expect more than this, and he sounds hardly symptomatic. One wonders whether he's used to a fairly chronically elevated potassium.

The low voltages are a large part of what's confusing, and maybe we can ascribe it to obesity, lung disease, whatever. Or again, baseline cardiomyopathy of whatever kind, which might help us explain the R wave progression too.

Or the punt answer, of course, is that hyperkalemia is the great imitator of the ECG and can do what it wants. But that's no fun.

 

[Gurby]

So, basically we don't know his medical hx...

Peaked t waves are reminiscent of hyperK, and possible kidney disease. I agree with brandon though I would expect wider qrs complexes. also, this ekg is pretty poor quality, as is the rest of the scenerio

Well, I didn't post it in the scenario forum for a reason

I didn't pay close enough attention to what apparently was the actual problem. Dispatched for the chest pain, on scene he complains of TIA-like symptoms and his AFib being somewhat out of control... I did puzzle over the EKG and point out the possible electrolyte problem to hospital staff (who were pretty dismissive of that idea, until the labs came back anyways). But nothing about the call made me inclined to go down that route of questioning too deeply. And while the T waves on the EKG are concerning, it really doesn't look like it's as severe as it apparently was (as everyone is pointing out).

 

[Ewok Jerky]

the K could have been an incidental finding.

 

[Carlos Danger]

Hyperkalemia would certainly be on my list of differentials, but as others have said, it's really not a great example of that.

Looks like some AF with some sort of conduction defect....maybe even some sort of antidysthymic toxicity.

Any renal or hepatic impairment?

I'm looking forward to Christopher's wisdom on this.

 

[D Brim]

I would respectfully disagree with those that say this is not typical for hyperkalemia. In short, it's suggested by the combo of the wide bizarre QRS AND the symmetric abnormal peaked T-waves.

As the potassium progressively increases T-waves become progressively more peaked (tall relative to QRS volume, and symmetric), QRS widens, and p-wave amplitude decreases. As the K gets higher and higher, more and more myocytes become unresponsive, because their resting potential never falls back below normal activation levels, e.g. the voltage-gated Na channels never get reset. As more and more myocytes become unresponsive (or depolarize slowly and ineffectively) it makes sense that the amplitude of QRS and T-waves both will decrease.

I think this EKG looks very similar to other hyperkalemia EKGs I've seen. Somewhere between the peaked T-waves and still narrow QRS of the earlier hyperkalemia, and the complete melding of the ever widening QRS and T-waves (sine waves) of very late hyperkalemia. His numbness and tingling also supports the differential. Hyperkalemia has complications on depolarization of nerves and muscles, just like it does on myocytes.

ACE inhibitors decrease urine production, therefore increasing K retention. Not sure what type of renal surgery the pt may have had, but you can imagine that it may have resulted in impaired renal function.

Most important thing to keep in mind, the EKG is almost never 100% diagnostic on its own. It's certainly helpful to suggest a differential (I believe it does suggest hyperkalemia) but you never know for sure until you get those labs back (K 8.0). I wonder what was the underlying cause of his hyperkalemia.

 

[Brandon O]

Well, I think we can all agree that it looks like hyperkalemia, it's just that it doesn't look like such advanced hyperkalemia as the labs suggested. Which happens (K is funny), but is still worth pondering on. It's also just a bit odd in that some features seem more advanced than others; in particular, although you're correct that your QRS/T amplitude will be lost eventually in hyperkalemia, it is usually quite a late finding, whereas the other features here are not so dramatic. I think that's the main incongruity.

All pretty academic though. There's probably no takeaway here except to remember that hyperkalemia is the syphilis of the ECG.

 

[BlueJayMedic]

We just did an inservice on hyperK and from the looks of that 12 those T waves are not large enough for us to treat this patient as per our protocol. The sine wave you are thinking of is such a late progression that you would have noticed the massive peak on the T wave well before it progressed to that. The large peak in II is up there but being a limb lead I wouldn't really consider that in the Dx. This a-fib, LBBB or borderline LBBB and Q waves are the only things that pop out to me in regards to this strip. Personally I do not look at axis in my pre-hospital 12's, the electrodes we use are too big and honestly I am not hitting the EXACT placement 100% of the time which you need in order to accurately determine totally accurate deviation. Also a moving pt and truck definitely do not help that either on Zoll or LifePak. Also taking into consideration his weight like you said... Without the lab value I would need some serious convincing in order to treat this guy.

All that being said, if this guy was on some form of K sparing diuretic like spironolactone mixed with the ACEI and kidney Hx at his size and weight I would be calling for ventolin and ca gluconate provided Dig wasn't in the med list.

 

[Brandon O]

For what it's worth, it's hard to go wrong with a little calcium (unless you infiltrate it, I suppose). Rapidly therapeutic, albeit in a temporizing fashion, and helpful diagnostically too. The dig thing has been shown to be largely unfounded. I'd have a low threshold for trying it if K is a consideration.