EKG in DKA

An young man presents to the ED tachypneic and dehydrated. His accucheck is “High” and your keen nose smells 4+ ketones. The nurse draws blood and starts a saline bolus.  She asks you if you want to start an insulin drip.

The EMT hands you the EKG below.

What does it show? What is your next step?

SCROLL DOWN FOR CASE ANSWER AND TO MAKE COMMENTS

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ANSWER:The EKG shows “Himalayan T-waves” and no you should not start an insulin drip yet. Before starting any insulin on a diabetic (or Lasix on a patient with CHF for that matter) you need to know what the potassium level is. Certain medications can cause or worsen hypokalemia and THAT can cause a potentially fatal arrhythmia. This patient had a Potassium of 1.8. Fortunately it was repleted prior to initiation of insulin therapy. The patient was admitted to the ICU.

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EKG Changes in Hypokalemia from Quick Essentials Emergency Medicine

More Common: Flat or inverted T-waves > ST-depression >U waves >prolonged PR & QRS intervals

Rare: V-tach & V-fib (especially if there is a history of heart disease or use of digoxin)

K>2.6: U wave, flat or inverted T wave, (U > T in V2+V3).

K<2.6: ST depression > Himalayan T waves > wide QRS

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