The following ECG (ECG 2) was recorded in a 40-year-old female admitted with severe trauma.
a) List the abnormalities
b) What is the underlying diagnosis?
c) List four pharmacological strategies for treatment of the demonstrated ECG abnormalities.
(40% marks)
(the college has not released their ECGs; the image above was appropriated from LITFL without any explicit permission but in the spirit of FOAM)
College Answer
a) Irregular rhythm
Absent P waves
Bizarre widened QRS complexes
Peaked T waves
b) Hyperkalaemia secondary to rhabdomyolysis
c) NaHCO 3
CaCl2
Dextrose/insulin
Frusemide
Salbutamol
(Resonium)
A note from the author: if I am correct in my interpretation of Chris Nickson's image filename, the serum potassium in the ECG above was 9.2 mmol/L.
Discussion
Previous appeances of hyperkalemia include Question 6.3 from the second paper of 2014, Question 18.2 from the first paper of 2013, and Question 23.1 from the first paper of 2012.
Characteristic features (if on were called upon to describe them) include the following:
- Broad QRS complexes
- Peaked T waves
- No typical bundle branch block pattern
- Left axis deviation
- Long PR interval (if P waves are even visible)
- Absent P waves (merged with QRS)
- Absent T-waves (merged with QRS)
- Ultimately, a "sine wave" ECG, which is where the P, T and QRS all merge into some sort of horrific mutant waveform. Cornelius et al (2010) published an ECG of this sort, taken from a woman with a K+ of 9.3.
References
From "the ECG made easy", by Hampton (2003), and ECGs shamelessly stolen from Life in The Fastlane without any sort of permission, but in the non-commercial spirit of free education
Cornelius, Brian G., Angela Cornelius, and Bobby Desai. "Identification of Sine Wave in Early Suspicion of Hyperkalemia." Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 11.1 (2010).