ECG of the Week – 19th June 2019 – Interpretation

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.


  • 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


  • 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


  • 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.