This EKG comes courtesy of Dr. Michael Kaiserian.
A 67 year old male presented to the Emergency Department complaining of generalized fatigue for two days. He was recently diagnosed with leukemia but did not start any treatment yet.
Vital signs: Pulse 40, Respirations 16, BP 130/80.
His EKG is below.
1. What is the rhythm?
2. How would you manage this patient?
The EKG shows a junctional escape rhythm.
The patient is stable. Atropine can be attempted. Causes for the bradycardia should be sought.
The EKG demonstrates a bradycardia at a rate of approximately 40. There are no P waves prior to the QRS complexes. There are retrograde P waves following the QRS complexes (best seen in the rhythm strip in lead II). The rhythm is regular, and the QRS complex is relatively narrow. This is consistent with a junctional escape rhythm. Junctional escape rhythms may present with absent P waves or with retrograde P waves.
When faced with a bradycardia, the algorithm below may be helpful to diagnose the rhythm.
Patients with bradycardia can be treated with atropine. If they are unstable, they should be treated with transcutaneous or transvenous pacing. In a stable patient, you have more time to analyze the rhythm and investigate potential causes.
Some potentially reversible causes include hyperkalemia, and medications such as digoxin, beta blockers and calcium channel blockers. So, obtaining a quick potassium level from a blood gas can be very useful. A medication history should be obtained as well.
This patient was found to have hyperkalemia. They were treated with IV Calcium. The repeat EKG is below:
It shows restoration of sinus rhythm. Patients with arrhythmias due to hyperkalemia should be treated with calcium followed by medications to shift potassium out of the blood.