ECG Case 118

This ECG is from a 35 yr old male Type 1 diabetic. He presents feeling generally unwell with abdominal pain and dyspnea.

ECG Case 118a LITFL Top 100 EKG

Describe and interpret this ECG

ECG ANSWER and INTERPRETATION

Rate:

  • 48 bpm

Rhythm:

  • Irregular
  • Nil P waves visible

Axis:

  • Right axis deviation

Intervals:

  • QRS – Prolonged

Additional:

  • ST Elevation leads I, aVL, V1-4
  • ST depression leads III, aVF
  • Bizarre broad QRS without typical BBB
  • Prominent T waves leads V3-6

Key abnormalities:

  • Slow atrial fibrillation
  • QRS Prolongation
  • High lateral ST elevation
  • Prominent precordial T waves

The differentials of these ECG findings are relatively broad but the immediate life-threats would be:

Other causes include myocarditis, cardiomyopathy and hypothermia.


CLINICAL OUTCOME

We must always take our ECG differentials to the bedside and consider them within the clinical presentation and scenario. ECG abnormalities in the acutely unwell diabetic should always prompt consideration of hyperkalaemia and acid-base disturbance as the primary cause. We must also be mindful that diabetic emergencies can be precipitated by acute cardiac ischaemia and also cause hypercoagulable states.

This patient had no associated chest pain nor any history of cardiac disease. The patients initial VBG showed diabetic ketoacidosis with severe hyperkalaemia, K 8.7 mmol/L. Following initial treatment of DKA and hyperkalaemia a repeat ECG was performed with K 5.4 mmol/L.

We can now see resolution of the QRS prolongation, restoration of sinus rhythm and normalisation of the ST / T wave changes. 

ECG Case 118b LITFL Top 100 EKG

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Emergency Medicine Specialist MBChB FRCEM FACEM. Medical Education, Cardiology and Web Based Resources | @jjlarkin78 | LinkedIn |

5 Comments

  1. Fibrillatory waves and No “P” wave suggestive of Atrial Fibrillation.

  2. More than likely sinus arrest with junctional escape vs AF. Looks most like mild musculoskeletal baseline artifact in ECG 1.

  3. Dr ELEFTHERIOS TSAGKAROPOULOS
    Dr ELEFTHERIOS TSAGKAROPOULOS

    1.AF or escape – junctional/ventricular – rhythm? Rather AF but nobody can be sure
    2. After stabilization I’d suggest a coronary angiography because he is a young diabetic man and these ECG changes are somewhat ischemic.
    Very nice case, thank you

  4. Lead I looks like A-Fib. Accelerated Idioventricular rhythm with ST elevations in V2, V3 and reciprocal depressions in leads II and AVF suggesting septal/anterior MI. Tall narrow T waves in precordials V3-V6 – you would want to R/O hyperkalemia

  5. António Tralhão
    António Tralhão

    Interesting case. Junctional rhythm ± AF. Underlying CAD cannot be ruled out but changes do normalize after hyperkalemia correction. Possible indication for elective ischemia testing, especially if positive troponin.

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