An 86 year old diabetic man presents to ED with a 1 month history of diarrhoea and fatigue and intermittent upper abdominal pain over the last week. His ECG is as below.

Interpretation:

• Rate: 48bpm
• Rhythm: Atrial fibrillation, couplet complexes
• Axis: Normal
• Morphology: Normal
• Intervals: QRS normal
• Other: peaked T waves (II >5mm, V3-5 >10mm)

What investigations would you like to do next?

• BSL 13.4 /Ketones 0.1
• VBG: pH7.20 CO2 44.1 O2 30.5 HCO3 18.8 Hb 90 Na133 K8.1, Lac 1.5, Cr649
• Trop: 29
• Urea 25
• LFTs/Lipase normal
• CXR mild pulmonary oedema

Management:

• K lowering strategy for severe hyperkalaemia (K>6): Insulin/dextrose, Sablutamol, Calcium Gluconate, IV fluids
• HDU admission – renal failure conservatively managed, nephrotoxic drugs including metformin withheld
• Gastroenteritis managed with IV antibiotics, fluids and antiemetics

Summary:

• Diagnosis made of Acute tubular necrosis 2 blastocystis gastroenteritis
• Acute on chronic diabetic renal failure 2 pre-renal AKI (last Cr 265) identified
• Hyperkalaemia 2 AKI
• Tented t waves most easily seen in precordial leads
• See loss of p waves in severe hyperkaelamia (K>8) due to impaired SAN automaticity and AVN conduction.

Further Reading:

• Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.