Case Study 1:
The tracing above from a 84 year old man found somnolent at home. The family was unable to establish contact during the day so Emergency Medical Services (EMS) was contacted. Initially the patient appeared dry and warm. The blood pressure was 80/40, the pulse weak and the respiration rapid. No information about medication or previous illness.
Because of the extreme bradycardia 1 mg of atropine was administered in the ambulance. At arrival at the hospital a 12 lead EKG was recorded:
How do you interprete these EKGs and which investigations would you perform to get closer to a diagnosis? How would you treat this patient?
– Mathias
{ 4 comments… read them below or add one }
Hyperkaliemia, I would take an arteriel blood sample for a quick analysis of electrolytes and creatinin. If the diagnosis is correct I would depending of the level of hyperkaliemia treat the patient with glucose-insulin drop….
Jacob,
Correct ! Arterial blood sample with K 7,8 – creatinine elevated (don’t recall exact value).
Which elements in the tracings indicate hyperkalemia?
Mathias,
Thank you for the quick response. The website seems very educative!
I’m guessing the low p-waves, the discretely widened qrs-complexes (sometimes more wide?) but mostly the large elevated t-waves. Maybe it was the accompanying acidosis? that gave him the bradycardia and low blood pressure? Or is it also a symptom of hyperkaliemia?
Thanks!
I agree – the peaked T waves in V2-V3 in the second tracing definitely suggest hyperkalemia as well as the flat P waves, the widened QRS and the extreme bradycardia. The latter may be seen in severe hyperkalemia (ventricular standstill). The low blood pressure – I suppose – is thus primarily due to the bradycardia. The patient went in and out of extreme bradycardia and was intermittent transcutaneously paced while the potassium level was corrected and the fluid balance restored. The patient suffered severe dehydration. As differentials I would consider digitalis intoxication.