Thursday, February 20, 2014

Complaint of Weakness. Alert. Hemodynamically Stable. What is it?

A male in his 60's, dialysis patient, complained of weakness.  He was alert and had no SOB or Chest pain.  BP was 85/57 with a pulse of 65.  Here is his ECG:

What is it?  See below.

This is pathognomonic for hyperkalemia and is nearly end stage, almost a complete sine wave morphology.  It seems miraculous that a patient can have this ECG and not be in profound shock, but it is true. 

He may die at any moment though.

His potasssium was 8.8 mEq/L.

There were access problems, but he did get insulin, glucose, bicarb, calcium gluconate, and albuterol, all while preparing emergency dialysis. The treatment resulted in the following ECG 36 min later:

Although still scary, it is now much better.  Are there P-waves?  Perhaps; I find it hard to tell.

After another hour and more treatment including more calcium, and still awaiting dialysis, this ECG was recorded, with a corresponding K of 6.6 mEq/L:
It appears slightly narrower, but still scary

The patient's level of consciousness deteriorated and he was intubated, taken for dialysis, and survived.  Here is his post dialysis ECG which is nearly identical to his baseline:

My next post will show another example of severe hyperkalemia with sine wave morphology.


  1. wow. 4th year med student (i can see the light at the end of the tunnel!!!!) here. just brushing up on my ECGs in preparation for my upcoming ER rotation and I found your website via AgileMD. Where has this been my entire med school career!?!?!! Wish I would have discovered this sooner, but I know I will be using it now and well into residency. thanks!!


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