A man in his 60s with syncope and ST depression. What does the ECG mean?

Written by Sean Trostel MD, peer reviewed by Meyers, Smith, Grauer, etc.A man in his 60s with a history of severe alcohol use disorder and epidural abscess on long-term ciprofloxacin presented to the emergency department after an episode of syncope while standing in line at a grocery store.He did not have chest pain.Here is his triage ECG:   What do you think?My interpretation:Sinus rhythm, normal QRS, widespread wavy ST depression leading into late T/U-waves with very prolonged QT. No evidence of OMI. QTc/QUc is in the range of 630 msec.What is the most likely cause of the patient ’s ECG findings, and what would be your first step in management?ECG is consistent with severe hypokalemia and/or hypomagnesemia causing prolonged QT (QU) at high risk of Torsades (which is polymorphic ventricular tachycardia in the setting of a long QT interval).A prior ECG was available for comparison:NormalOne might be tempted to interpret the ST depression as ischemia, but as Smith says," when the QT is impossibly long, think of hypokalemia and a U-wave rather than T-wave. "Check out this case: Are These Wellens ' Waves??The Queen of Hearts PM Cardio AI app was fooled into saying " OMI with low confidence, " butshe has never been trained in hypokalemia.  We just finished training version 2 with some cases of hypokalemia, so that is in the future.  Moreover, the Queen is only supposed to be used with a high pretest probability of ACS/OMI.The patient ’s VBG resul...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs