14: EKG in a Diabetic

An young man presents to the ED tachypneic and dehydrated. His accucheck is “High” and your keen nose smells 4+ ketones. The nurse 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?

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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 Side Kick: Emergency Medicine
K > 2.6: U wave, flat T, (U>T in V2+V3).
K < 2.6: Himalayan T waves > wide QRS

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