An anonymous paramedic sent this.
A 60-something with past history only of colon cancer called 911 for non-specific generalized malaise.
The medics state that he was ill appearing.
They recorded an ECG:
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| What do you think? |
This is extremely wide, and even if it is VT, it is so wide that there must be hyperkalemia or a severe Na channel blocking overdose. The patient was not on a sodium channel blocker.
The paramedic knew instantly what it was (he credits his regular reading of this blog!)
The patient was only a couple blocks from the hospital, so there was no time for treatment before arrival.
K was 8.9 mEq/L.
Etiology was a combination of NSAID and obstructive nephropathy, with a Cr > 20 (!). Estimated GFR of 2.0.
The potassium was brought down and the patient ultimately did well.
Many pre-hospital protocols only address hyperkalemia in the context of CPR and permit bicarb administration. For someone who's still alive — as in this case — and with an EKG so dramatically suggestive of elevated K I would assume bicarb, calcium, and continuous albuterol. Any preference on calcium gluconate vs chloride?
hi Steve!
even i suspected hyperK… interesting and frightening how a medicine as benign-appearing (i gave it to my 11 year old granddaughter three days ago) such as an NSAID can destroy renal function and cause this ecg. it appears to be pre-sinusoidal.
thank you for this case.
If CaCl, you just have to be careful that the IV is perfect (no extravasation). One "amp" of CaCl = 3 "amps" of CaGluconate, so easier to administer. IM Terbutaline is great substitute for albuterol. See this post: https://hqmeded-ecg.blogspot.com/2013/12/terbutaline-and-albuterol-for-lowering.html
I won't be surprised if it is sinus rhythm.
hard to tell, especially since P-waves can disappear in hyperK because of absence of atrial activity, in spite of the possibility that the sinus node is driving the ventricle.