EKG of the Week 2019 8-12

This EKG comes courtesy of Dr. Mohammed Hassan, Dr. Savarese and PA Vitulli.

A 79 y/o female complained of weakness and dyspnea. She had a past medical history of COPD, CHF, and CLL. She was started on a new chemotherapy drug (venetoclax) one day prior to arrival. 

 

V/S: P 119, BP 72/39, RR 14, T 97.1 F

Her EKG is below:

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 1.     What does the EKG demonstrate? 

2.     What is this diagnostic of?

3.     How would you manage this patient?

ANSWER

The EKG demonstrates a sine wave pattern

This is diagnostic of hyperkalemia.

 The patient should be treated immediately with calcium. Other measures for hyperkalemia should be initiated as well.

 

 

 

The EKG demonstrates a sine wave pattern. It looks almost like v-tach but it is slower. This is diagnostic of hyperkalemia. Whenever you see something that looks like “slow v-tach” think about hyperkalemia.

Hyperkalemia causes a series of changes to the EKG. An early sign is peaked T waves. This is followed by flattening of P waves, widening of the QRS complex and ultimately a sine wave.

A sine wave pattern on EKG represents life threatening hyperkalemia. This first step in treatment should be IV calcium. This stabilizes the cardiac membrane against the effects of the hyperkalemia. It does not lower the potassium level. You should start to see the effects of the calcium on the EKG within minutes. The QRS should start to narrow and ultimately return to normal. To fix the potassium level, give insulin (with glucose to prevent hypoglycemia), albuterol, perhaps bicarb and ultimately dialysis.

This patient had a potassium level of 9.7. She also had a uric acid level of 33.9, and a Phosphorus of 18.5. She was found to be in tumor lysis syndrome due to her chemo drug (venetoclax).

 

The patient required multiple doses of IV calcium. She also received IV insulin, D50, bicarb, and nebulized albuterol. She then went for emergent dialysis.

EKG of the Week 2019 2-17

This EKG comes courtesy of Dr. Ross Hardy.

 

A 62 year old male with a history of diabetes presents for generalized weakness for a few days. He also reports nausea and vomiting. He has no fever. No chest pain. Mild shortness of breath.

Vital signs: Pulse – 50, Respirations – 22, BP 160/90, O2 sat 99%, blood glucose 110.

His EKG is below.

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1.      What does the EKG demonstrate?

2.      How would you manage this patient?

ANSWER:

The EKG demonstrates bradycardia with peaked T waves, loss of P waves, and a widening of the QRS complex. This is consistent with hyperkalemia. 

The patient should be treated with calcium for myocardial protection. A potassium level should be checked and other medications to lower the potassium should be administered.

 

 

The EKG shows sinus bradycardia with a PAC. There are peaked T waves, loss of P waves, and a widening of the QRS complex.

Labs revealed BUN 90, Creatinine 9, potassium 8.1.

The patient was treated with calcium which improved the EKG. He also was given glucose/insulin and albuterol and was sent for emergent dialysis.

Hyperkalemia causes a series of changes to the EKG. An early sign is peaked T waves. This is followed by flattening of P waves, widening of the QRS complex and ultimately a sine wave. Whenever you see a wide QRS complex with a bizarre rhythm or what looks like “slow V-tach”, think about hyperkalemia.

 

 

EKG of the Week 2018 5-27

This EKG comes courtesy of Dr. Litvak and Dr. Calabro.

A 59 y/o male with no significant past medical history presented to the ED complaining of weakness and shortness of breath. He had been fatigued for several weeks. He presents drowsy.

V/S: Pulse 120, Respirations 28, BP 180/90.

His EKG is below.

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  1. What does the EKG demonstrate?
  2. How would you manage this patient?

 

ANSWER:

The EKG shows a wide QRS complex with an irregular rhythm.

This EKG is concerning for hyperkalemia. This patient’s Potassium was 9.9. He was treated with calcium, insulin, glucose, albuterol, bicarb and emergent dialysis.

 

Hyperkalemia causes a series of changes to the EKG. An early sign is peaked T waves. This is followed by flattening of P waves, widening of the QRS complex and ultimately a sine wave. Whenever you see a wide QRS complex with a bizarre rhythm or what looks like “slow V-tach”, think about hyperkalemia.

This patient was given calcium. The repeat EKG below shows some improvement in the rhythm but the QRS remained wide.

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The patient was found to have AKI with BUN 225 and Cr 25. Blood gas showed pH 6.95, pCO2 16, HCO3 4. A foley was placed and the patient was anuric.

The patient was sent for emergent dialysis. After dialysis the EKG (below) shows a normal sinus rhythm with a narrow QRS complex.

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