Found comatose with prehospital ECG showing " bigeminal PVCs " and " Tachycardia at a rate of 156 "

This patient with a history diabetes was found with a GCS of 4.Prehospital EKG and strips (not shown) had " heart rate 156 " (according to the computer interpretation) and " Bigeminal PVCs "The prehospital 12-lead looked just like the first ED ECG:What do you think?Answer: The " bigeminal PVCs " is really a QRS followed by a very narrow peaked T-wave, which was so narrow that it was mistaken for a separate QRS.  The heart rate is 78, not 156.  Notice also thevery long ST segment, most easily seen in inferior leads.This ECG is pathognomonic for severe hyperK, and the long ST segment is all but pathognomonic for hypocalcemia. So I knew immediately that the patient needed a lot of IV calcium, and, based on the prehospital ECG, we gave 6 grams of calcium gluconate before even drawing blood for lab values. When we did get a chem back (drawn after 6 g Ca gluconate), the K was 9.0 mEq/L and the ionized calcium was not reported because it was too low.The patient had a glucose of 1400, was severely dehydrated, and after receiving 4 liters of fluid, albuterol, and insulin, the K had dropped precipitously to 5.8 and the ECG improved:The Calcium AFTER 6 g of treatment was 8.2 mg/dL.Cr was 8.0 (previous was normal).  The patient had hyperK due to acute renal failure.Learning Points:1. Learn all the different pathognomonic ECGs of severe, life threatening hyperK.2. A long ST segment is typical of hypocalcemia3. Immediate treatment of HyperK is calcium. It is safe even w...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs