Thursday, February 22, 2024

How will you save this critically ill patient? A fundamental and lifesaving ECG interpretation that everyone must recognize instantly.

Written by Pendell Meyers

A woman in her 30s called EMS for acute symptoms including near-syncope, nausea, diaphoresis, and abdominal pain. EMS arrived and found her to appear altered, critically ill, and hypotensive. 

An ECG was performed:

What do you think?

Extremely wide complex monomorphic rhythm just over 100 bpm. The QRS is so wide and sinusoidal that the only real possibilities left are hyperkalemia or Na channel blockade. Hyperkalemia is by far more common.

Indeed, further history revealed two missed dialysis sessions. And of course on exam she has a dialysis fistula.

EMS reportedly gave 4 grams of calcium (unknown whether CaCl or gluconate) and 50 mEq of sodium bicarbonate. There was concern that the rhythm might represent ventricular tachycardia, so lidocaine was given and one attempt at cardioversion was performed. It is unclear what changes happened to the rhythm based on the EMS interventions, but the patient arrived to the ED remaining critically ill and with a very wide complex reported (no ECGs from ED available sadly).

Hyperkalemia was diagnosed and more treatment was given including more calcium, bicarb, insulin/dextrose, and albuterol.

The potassium level returned at 9.7 mEq/L.

Emergent dialysis was prioritized after stabilization. 

She did well and stabilized after dialysis. 

Here is her ECG the next day with normal potassium level:

She did well.

See our other countless hyperkalemia cases below:

General hyperkalemia cases:

A 50s year old man with lightheadedness and bradycardia

Patient with Dyspnea. You are handed a triage ECG interpreted as "normal" by the computer. (Physician also reads it as normal)

Is this just right bundle branch block?

A 60-something who has non-specific generalized malaise and is ill appearing.

HyperKalemia with Cardiac Arrest. 

Peaked T waves: Hyperacute (STEMI) vs. Early Repolarizaton vs. Hyperkalemia

What will you do for this altered and bradycardic patient?

I saw this computer "normal" ECG in a stack of ECGs I was reading

What is the diagnosis?

Found comatose with prehospital ECG showing "bigeminal PVCs" and "Tachycardia at a rate of 156"

An elderly woman found down with bradycardia and hypotension

A Very Wide Complex Tachycardia. What is the Rhythm? Use Lewis Leads!!

Cases of hyperkalemia mimicking OMI:

Acute respiratory distress: Correct interpretation of the initial and serial ECG findings, with aggressive management, might have saved his life.

Another deadly and confusing ECG. Are you still one of the many people who will be fooled by this ECG, or do you recognize it instantly?

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