A woman in her 60s with large T-waves. Are they hyperacute, hyperkalemic, or something else?

 Case written by Brandon Friedman M.D., edits by MeyersA woman in her 60s with a history of chronic atrial fibrillation on Eliquis, ESRD on hemodialysis, type-II diabetes mellitus, prior CVA, hypertension, and hyperlipidemia presented to the emergency department with multiple complaints after missing dialysis. She described a feeling of general unwellness, diarrhea, right-sided abdominal pain, bilateral leg pain, bilateral leg swelling, and diffuse itching. She missed her last two dialysis appointments, with her last session occurring one week prior to presentation. On initial assessment, she was found to be tachycardic, for which an ECG was ordered and is shown below (no prior available):What do you think?When first evaluating this ECG, the physicians taking care of her were immediately concern about the T waves in multiple leads, especially the inferior leads where they appear too large for their QRS complexes. They were considering hyperkalemic or hyperacute T waves there. Due to the patient ’s reported history of missing dialysis, the high-voltage of the T-waves initially raised concern for hyperkalemia. A VBG was ordered, which reported a normal potassium level of 4.9 mmol/L. This value was subsequently confirmed as 5.0 mmol/L on a formal electrolyte panel.So if the high-voltage T-waves are not a result of hyperkalemia, what ’s causing them to be so large? Like the team did in this case, let ' s start over from the beginning and interpret the entire EC...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs