Last week one of our second-year fellows was called into the ER for a potassium of 9.9 mEq/L. The EKG you see above was waiting for him. He arranged for emergent dialysis. In the morning the patients EKG looked like this:
Here is the time line of events:
- 17:24 Na 128, HCO3 9, Cl 103, BUN 100, Cr 5.6 (no potassium was reported out on the initial labs)
- 18:06 First EKG done
- 18:28: K=9.9
- 18:28: U/A Sp Grav 1.012, pH 5, random drug screen positive for opioids
- 18:45: ABG 7.05/37/408/10
- 18:45: urine Na 89, urine Cr 50.5, FENa 4.7%
- 23:00 initiate dialysis: 2 hours on 1 K bath
- 01:00 complete dialysis
- 03:30 Na 140, K 5, Cl 107, HCO3 16, BUN 67, Cr 3.8, Ca 9.1, Phos 6.4, Mg 1.4, CPK 941
- 03:30 ABG 7.22/40/117
- 09:20 Na 142, K 4.8, Cl 111, HCO3 15, BUN 63, Cr 3.2
- 10:00 ABG 7.20/42/96
This patient had AKI due to prolonged decreased po intake along with a loop diuretic and ACEi. The patient initially was anuric but rapidly began to recover and by the next morning was making over 100 mL of urine an hour.
His initial EKG is the best example of a sine wave from hyperkalemia I have ever seen. Below is a cardiac cycle from V4. With a quick glance it may look like a very wide QRS complex with the t wave somewhere to the right of the picture. In reality, the QRS duration is only 176 msec and the large upward thrust is the peaked T wave.
EKG Changes with hyperkalemia
- Peaked T waves
- Shortened QT interval
- Widened QRS
- Sine wave
That’s a scary-looking EKG! No debate about whether to drag the dialysis nurse in on this one (though hopefully he wasn’t already making 100 cc/hr of urine while he was still on dialysis…) Great post.
flat p wave, widened qrs , prolonged pr interval and tall t wave…
yeah….
that's it…