Friday, June 19, 2015

Cardiac Arrest and ST Elevation: You Should Learn to Recognize This!

The following case was incredibly interesting for other reasons, but in order to maintain confidentiality and also to allow for a subsequent case report by the physicians caring for the patient, I limit the discussion to the ECG findings and their etiology.

A man was resuscitated from an Asystolic Cardiac Arrest with Epi, bicarb, and chest compressions.  He was in shock.  

Here was the initial 12-lead:
This is nearly pathognomonic of at least one condition.  What is it?












There is sinus rhythm with a prolonged QRS, right precordial ST elevation, and very peaked T-waves in V4-V6.   This is hyperkalemia until proven otherwise.

It is possible that the ST elevation is due to STEMI, but unlikely.

Hyperkalemia often produces a Brugada-like right precordial PseudoSTEMI pattern.

The pH was 6.65, with a K of 7.5 mEq/L.

Here are 7 other examples of PseudoSTEMI due to HyperK:
1. http://hqmeded-ecg.blogspot.com/2013/06/a-tragic-case-related-to-last-post.html
2. http://hqmeded-ecg.blogspot.com/2013/11/you-must-recognize-this-pattern-even-if.html
3. http://hqmeded-ecg.blogspot.com/2013/06/hyperkalemia-and-st-segment-elevation.html
4. http://hqmeded-ecg.blogspot.com/2013/06/this-ecg-is-pathognomonic-of-life.html
5. (there are 3 in this post): http://hqmeded-ecg.blogspot.com/2013/02/right-bundle-branch-block-with-st.html


There is remarkably little literature on ECG findings in severe acidosis.
Here is a case in which one patient had 2 cardiac arrests on separate dates, both due to cocaine use, and both with severe acidosis and a bizarre Brugada-like ECG. 



He was given Calcium, bicarbonate, and Insulin


This ECG was recorded 30 minutes after the first:
Same findings, but less pronounced, and slower rate

The pH at this point was 6.80, with a K of 6.2 mEq/L.  More Calcium and Bicarb were given.



At 1 hour, with a pH of 6.95 and K of 7.2 (difficult to control), another ECG was recorded:
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12 comments:

  1. I am not that good, but i think the first EKG is irregular,

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  2. Hey Steve thanks for the great case! Hyper K is the syphilis of EKGs. Steve was this PTs hyper K due to shock and acidosis exclusively? Also what caused the shock? Thanks!

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    1. This comment has been removed by the author.

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    2. To give the cause of the shock and acidosis might reveal the patient's identity, so I cannot give it. I will say it was toxic.

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  3. Is there a correlation between the potassium level and heart rate? It appears that it speeds up as the potassium rises, seems like it would be the other way around.

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    1. In such a criticlly ill patient, there are too many variables to predict the response to hyperK.
      Steve Smith

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  4. It looks like the T wave is peaked because of a buried p wave.

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    1. I'm not exactly sure what bump you are referring to, but you may be right. But hyperK usually flattens P-waves do where they may be invisible, even though the sinus is still driving the rate

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  5. Did the patient survive? there seems to be an ongoing hyperkalemia despite improving ABG, which is ominous..

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    1. Marco,
      you are correct. It is ominous and the patient did not survive.
      Steve

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  6. Hi Steve, are these changes purely due to the high K?

    These changes are not what I'm looking for with hyper k. Was calcium okay?

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    Replies
    1. Wayne, there may be some contribution of acidosis, but hyperK alone can do this.
      Steve

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