Elderly patient feeling generally unwell. PMHx of T2DM, hypertension, IHD, CCF, osteoarthritis. Describe the ECG.

TOP 100 ECG QUIZ LITFL 027 2

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Main Abnormalities

  • Bizarre appearing complexes
  • Marked T wave peaking in V2-6.
  • Gross QRS prolongation (~200 ms)
  • Some leads (I, aVR) are starting to take on a sine wave appearance

Diagnosis

The combination of…

  • Bizarre complexes
  • QRS prolongation
  • Peaked T waves
  • Sine wave appearance

… are all strongly suggestive of severe hyperkalemia.

This patient had a serum K of 9.2 mmol/L!

In this elderly patient with multiple medical problems, causes could include renal failure (e.g. due to diuretics, NSAIDs, intercurrent illness) or treatment with ACE-inhibitors, spironalactone or K-supplements.


CLINICAL PEARLS
The push-pull effect
  • Hypokalaemia creates the illusion that the T wave is “pushed down”, with resultant T-wave flattening/inversion, ST depression, and prominent U waves
  • In hyperkalaemia, the T wave is “pulled upwards”, creating tall “tented” T waves, and stretching the remainder of the ECG to cause P wave flattening, PR prolongation, and QRS widening

TOP 100 ECG SERIES


Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

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