Monday, December 28, 2015

K 8.7 mmol/l ! You want to know what the EKG shows??

Case: 


  • Women in her 60's presents with septic shock from HCAP, currently bacteremic. She was oliguric. On admission her Serum Potassium was 8.7 mmol/l. Prior to admission medications included PO Bactrim for PCP prophylaxis. 
  • Focus of this article is to display the EKG changes associated with hyperkalemia in this patient. 
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EKG at 1am: 

Initial EKG with K 8.7 mmol/l showed:

  1. Almost sine wave pattern
  2. Wide complex tachycardia 

We treated the patient with IV calcium gluconate, Normal saline boluses, IV Furosemide, Albuterol nebulizer, Sodium bicarbonate drip, Insulin Dextrose.

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EKG at 2am: 

One hour post treatment, K was 7.1mmol/l. A repeat EKG showed:

  1. 1st degree AV block
  2. Prolonged QRS interval
  3. QTc prolongation
  4. Resolution of sine wave pattern.

We repeated the above mentioned treatments, consulted renal (just to feel safe).

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EKG at 3am: 

One hour later, K was 6 mmol/l. A repeat EKG showed:

  1. Non specific ST changes. Otherwise normal EKG
  2. Resolution of AV block. 
  3. QRS no longer prolonged. 


Eventually her urine output improved with IV fluids and lasix. K level normalized in 6hrs. Did not need dialysis.

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Pearls:


  • Hold bactrim as it can cause hyperkalemia due to blockade of the collecting tubule sodium channel by trimethoprim (an action similar to that induced by the potassium-sparing diuretic amiloride); this is most common in HIV-infected patients who are treated with high doses, but normal doses can produce a modest elevation in the plasma potassium concentration in non-HIV-infected subjects
  • Not every hyperkalemia patient has tented T waves on EKG. Peaked T waves are only one of the many EKG manifestations of hyperkalemia. 


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Stuff: 

As a general rule, mentioned below are the EKG findings associated with various stages of hyperkalemia:


  1. K >5.5 mmol/L is associated with repolarization abnormalities
      1. Peaked T waves (usually the earliest sign of hyperkalaemia)
  2. K >6.5 mmol/L is associated with progressive paralysis of the atria:
      1. P wave widens and flattens
      2. PR segment lengthens
      3. P waves eventually disappear
  3. K >7.0 mmol/L is associated with conduction abnormalities and bradycardia:
      1. Prolonged QRS interval with bizarre QRS morphology
      2. High-grade AV block with slow junctional and ventricular escape rhythms
      3. Any kind of conduction block (bundle branch blocks, fascicular blocks)
      4. Sinus bradycardia or slow AFDevelopment of a sine wave appearance (a pre-terminal rhythm)
  4. K >9.0 mmol/L causes cardiac arrest due to:
      1. Asystole
      2. Ventricular fibrillation
      3. PEA with bizarre, wide complex rhythm
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References: 
1. www.lifeinthefastlane.com
2. UpToDate

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