What happens if you do not recognize this ECG instantly?

Written by Pendell MeyersA young man in his 20s with history of end stage renal disease and dialysis presented for acute chest pain. His last dialysis was 4 days ago. He was very hypertensive and short of breath, but oxygen saturation was normal.Triage ECG:What do you think?Pathognomonic for severe, life threatening hyperkalemia. QRS widening, PR interval prolongation (I believe those are P waves best seen in V1 and V2, but it matters not), and peaked T waves are apparent.  There is also a large R-wave in aVR, which is typical of severe hyperkalemia.Prior ECG on file from 12 days ago:Baseline LVH with repolarization abnormalities.It is unclear if hyperkalemia was immediately diagnosed from the triage ECG. 15 minutes later there was a change in the cardiac monitor and the patient became lethargic:What is the rhythm here?I believe it is ventricular tachycardia (with sine wave appearance and extreme QRS widening due to hyperkalemia) for the first two thirds, then the VT breaks and we glimpse one or two beats of normal conduction (widened by the hyperkalemia), followed by likely VT from a different focus than before (different morphology compared to the prior run of VT).The patient was still alert, and so he was sedated given etomidate and cardioverted, simultaneously with calcium, insulin, dextrose, and albuterol.After these therapies, this ECG was recorded:Dramatic improvement, with QRS narrowing and reorganization of rhythm.The serum potassium level returned at 9.3 m...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs