31: Vomiter’s EKG

A 50-year old man presents to the ED with nausea, vomiting and generalized weakness. He has no known past medical history, but has not seen a doctor in “years”. He denies chest pain, abdominal pain, change in bowel movements, headache and fever. He has no other complaints.

On exam his vital signs are normal, but he just doesn’t look right. His tongue is a bit dry. There is no JVD. Lung have a few bibasilar rales, but are mostly clear. Heart sounds are normal. The abdomen is non-tender without mass. He has trace bilateral edema.

Below is his EKG. What does it show? What do the second EKG show?

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Answer: Hyperkalemia

EKG #1 shows a ”sine wave” pattern with a very wide QRS from hyperkalemia.   The potassium was 9.7 and was due to new onset severe acute renal failure.

 The second EKG shows a junctional bradycardia, another possible finding in hyperkalemia.

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Selected text on “EKG & Electrolytes” & “EKG & Wide Complexes” from

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EKG:     ELECTROLYTES:
K-high:    K<7: peak T wave, S wave in I or V6, S1Q3T3.
K=7-8: ST elevation, wide:P/QRS, AV block, bradycardia   K>8: wide QRS, V-fib
K-low:        K>2.6: U wave, flat T wave, (U>T in V2+V3).
K<2.6: ST depression > Himalayan T waves > wide QRS
Ca high:    Short ST & short QT (QTc less than 350), long PR & long QRS
Ca-low:    Long QT often with normal T & long ST, short PR & short QRS, > flat or inverted T
Mg-high:    Short PR, peak T wave, wide QRS, AV blocks
Mg-low:    Long QT usually with flat T wave, a-fib, ventricular and supraventricular dysrhythmias   

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TACHYCARDIA: WIDE
WIDE Irreg:    A fib c Bundle Branch Block, WPW(esp if HR>200), torsade, polymorphic VT
WIDE Reg:    VT, ^K, Ischemia, recent cardioversion, meds(procainamide, flecanide, TCA’s)
(WPW is so fast it may look regular)
AIVR:        Accelerated Idio-Ventricular Rhythm: Rate <120.  Causes: AMI, reperfusion, Digoxin.
Rx:     Benign, don’t treat it.  Giving lidocaine could cause asystole.
V-Tach:    Rate 120-200, regular, wide.  PVCs, 3rd degree AVB, QRS > 140, extreme LAD, concordant QRS’s
Sustained = >30sec or BP; capture/fusion beats.  Adenosine sensitive V-tach: admit ICU
Cx=ABCs:    Air (O2), Blood (ACS, Hb, BP), Catechol, Drug (coke, TCA, opiate, Dig), Electrolytes (K, Mg)
Also: CM, valve, Drugs (pentamidine, EtOH, hydrocarbons), trauma, long QT, sarcoid
Torsade:    Polymorphic V-tach, rate 150-300, irregular.  Usually self terminates but may cause V-fib.
Causes:     See long QT
RF:    Age, female, CHF, bradycardia
Rx:        Mg up to 10g, 200J.  Prevent recurrence ĉ isuprel or pacing at 90-120.
NO: amiodarone or procainamide as both prolong the QT interval.
Wide SVT:    Only surefire Dx is to have an old EKG.  Brugada himself missed 2%.  Assume V-tach
WPW:         Wide & irregular, bizarre (mimics V-tach), rate >200 cause V-fib.  Rx: cardiovert, procainamide

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