Triage: Vomiting for 2 weeks getting worse

History of Present Illness: A 38-year-old male presents with generalized weakness, lightheadedness, and shortness of breath for the last 2 days, and vomiting for 2 weeks with 20 pound weight loss. He denies diarrhea but is not keeping much down.  No abdominal pain, chest pain, fever or chills or other complaints

Vital Signs: HR 116, BP 108/72, T 98.2, RR 22

Physical Exam: Alert, oropharynx a bit dry, tachycardic, abdomen benign

An ECG is done

Computer Read: NSR 96, marked ST depression consider subendocardial injury

 

What is the most likely cause of ECG findings in this patient?

  • A) PE
  • B) Electrolyte issue
  • C) ACS
  • D) PTX

SCROLL DOWN FOR THE EKG ANALYSIS & 1-MINUTE CONSULT

 

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ECG interpretation:

Interpretation: there is borderline tachycardia (rate >90 bpm), which is sinus as well ST depression followed by large broad T-U fusion waves.  Ischemia is a possibility but this ECG along with the clinical picture is highly suspicious for severe hypokalemia, putting the patient at risk of fatal arrythmias, especially torsade de pointe.  It is critical to avoid nausea medicines that could further prolong his QT interval such as Zofran, Reglan, Compazine or most agents.  Benadryl, benzodiazepines or Decadron shouldn’t prolong the QT interval although Decadron could worsen any metabolic alkalosis.  If this patient codes make sure to minimize epinephrine use and completely avoid bicarb as both decrease serum potassium levels.  Bicarb should almost never be used in ACLS as it has been class III since 2010.

QUIZ ANSWER:

  • A) PE
  • B) Electrolyte issue – CORRECT.  K was 2.1
  • C) ACS
  • D) PTX

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CASE CONCLUSION: K was 2.1, bicarb 43, Mg normal, troponin and D-dimer were normal.  He was admitted and potassium repleted.  Sent home tolerating POs, feeling better with GI and Renal follow-up