The ECG below is from a 66 year old diabetic man who has presented with sepsis.

Interpretation

• Rate: 72
• Rhythm: broad complex (likely inherent rhythm with p wave flattening)
• Axis: Extreme LAD
• Morphology: LVH criteria,  peaked T waves (and ‘peaked’ inverted T was in aVL as seen with below diagnosis in LVH) flattened p waves best seen in V3 and V6, pseudo-brugada pattern in V1-2 (likely due to Na channel blockade effect seen in hypercalcaemia)
• Intervals: QRS >120, PR (seen best in V3 and V6) 400
• Summary: Hyperkalaemic ECG

Hyperkalaemia

• usually seen with K levels > 6.0
• Starts with increase in T wave amplitude as repolarisation is affected, followed by changes seen in atrial paralysis with p wave flattening or widening with eventual disappearance, and PR prolongation.
• Levels of >7 are associated with conduction disruption, with bundle branch and fascicular blocks as well as bradyarrhythmia and QRS widening.
• K>9 will be seen as the pre-terminal sine wave, followed by asysle, PEA with board complex patterns and VF.

Clinical Closure

K was 8.1

Further Reading – Textbook:

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