This ECG Pattern Told the Story When the Patient Could Not

 Submitted by Spencer Lord MD, written by Alex Bracey with edits by Meyers and SmithA patient presents as a transfer from an outside facility. On arrival, he appeared air hungry, volume overloaded, and agitated. EMS was not available for a history at the time and the patient was unable to provide any details regarding his circumstances. During the initial minutes of his resuscitation the following ECG was performed:This ECG is pathognomonic. What is it?Sinus bradycardia with first degree AV blockWide, bizarre QRS complexes with STE in V1 and aVRPeaked T waves in I, II, V4-V6QRS duration is nearly 200 ms.There is a large R-wave in aVR and V1 (RBBB pattern)There is ST Elevation in V1, V2, and aVRThere is upsloping ST depression in V4-V6 with a wide and peaked T-waveRecall the ECG findings of hyperkalemia (aka the " Killer B ' s " ) summarized in this graphic created by Pendell Meyers:The treating emergency physician immediately recognized this to be representative of hyperkalemia. He initiated treatment with calcium gluconate 2g calcium gluconate, insulin, bicarbonate, and lasix with modest improvement in his symptoms. Approximately 20 minutes later a repeat ECG was performed:Similar to initial ECG with more prominent P waves.The similarities between these two ECGs is likely due to underdosing of calcium. The minimum dose of calcium gluconate required to rapidly stabilize the myocardium in hyperkalemia is 3g of calcium gluconate or 1g of calcium chloride (calcium chloride ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs