Very Wide QRS Tachycardia: VT or not?

70 yo h/o DM COPD s/p PPM c/o AMS

Image 1

The 12L shows regular very wide QRS tachycardia (~120 bpm). Pacer spikes can be seen in lead I. This is a V-paced rhythm in a patient with hyperkalemia (6.8).

571

Junctional Rhythm with Hyperkalemia

Vignette: 40 yo with h/o HTN, HLD and CKD c/o chest pain. 

Image 1

This is a regular, wide QRS rhythm with a ventricular rate of about 37 per minute with no discernible P waves and tented T waves in the precordial leads. This is junctional rhythm, intraventricular conduction delay with hyperkalemia (K7.2) as manifested in the 12L ecg with T wave tenting. 

#689

MAT and HyperK

This tracing is from an adult pt with h/o HTN, DM, CHF and end stage renal disease c/o of pleuritic chest pain and cough. 

Image 1 - Case

The tracing shows an irregular narrow complex tachycardia with P waves of different morphologies (multifocal atrial tachycardia), peaked T waves in the precordial leads (esp in V3 and V4)suggestive of hyperkalemia and tall R waves in V6 and deep S in V2 (suggestive of LVH).

Lab investigation showed Hb 10, WBC - 7, PC - 200, Trop -0.2, K 8, Creatinine - 20 and CXR showed cardiomegaly and congestive heart failure worst that a prior study.

The case was managed as critical hyperkalemia (K-8.0). Calcium gluconate, NaHCO3, and glucose-insulin was given and dialysis was eventually done. The chest pain was thought to be due to non-ischemic in nature (had a recent normal angiogram). The troponin elevation was attributed to the chronic kidney disease. Eventually discharged after a few days.

443

Hyperkalemia

Elderly brought in due to altered mental status.

Image 1 - ECG case

What is the ECG saying?

This is a regular very wide QRS rhythm with no distinct P waves, peak T waves (noted from V3-V6 and II, III and aVF) and sine wave pattern or the disappearance in the delineation between the S and T waves. These are all indicative of hyperkalemia (K - 8). This patient had acute renal failure.

#307

Multifocal atrial tachycardia/hyperkalemia/LVH

This tracing is from 40 yo pt with h/o HTN, DM, CHF and end stage renal disease c/o of pleuritic chest pain and cough. 

 

Figure 1 - ECG case

What is the ECG interpretation?

Tented T waves of Hyperkalemia

A 45 yo with h/o DM, HTN, CHF and CRF body malaise and dyspnea.

Figure 1 - ECG case

What is causing this ECG change?

Really Wide QRS Tachycardia

A 50yo pt with h/o of HTN, DM  and end-stage renal disease is admitted due to dyspnea and change in sensorium.

 

Figure 1

Hyperkalemia and hypocalcemia

 A 60F with CRF due to HTN and a recent neck surgery came in due to leg  pain. What is your ECG interpretation?

Figure 1 - ECG case

The rhythm is sinus with peak T waves in the precordial leads and a prolonged QTc (500 ms). Labs revealed a K of 7 and Ca is 5. The neck surgery was parathyroidectomy which can explain the hypocalcemia. Patient had dialysis and Ca was replaced.

Interpretation: Sinus rhythm with ECG manifestations of hyperkalemia (peak T waves) and hypocalcemia (prolonged QTc).

#369

Hyperkalemia + RBBB

This is the 12L ECG of a 70 yo patient with h/o of HTN, hyperlipidemia DM, CHF and ESRD c/o vomiting.

Figure 1

The 12L showed a regular wide QRS rhythm at rate of about 94 bpm, RBBB morphology and left anterior fascicular block pattern. P waves are best seen in long lead II. The QRS duration is about 200 ms which is very wide. Tall and tented T waves can be appreciated in V3. This ECG is highly suggestive of an ECG pattern of a patient with hyperkalemia.

Potassium came back at 6.5. Calcium gluconate, glucose/insulin and sodium bicarbonate were given and was dialyzed.

Interpretation: Sinus rhythm, right bundle branch block, left anterior fascicular block, hyperkalemia. 

#632

Hyperkalemia

An 80yo with history of HTN, dyslipidemia, CAD, s/p CABG on lisinopril, furosemide, potassium and spironolactone was admitted due to syncope. BP  systolic 70's PR 80 RR 18 and O2 sat 95 at 5L O2. Patient is lethargic with dry oral mucosa, clear breath sounds, regular cardiac rhythm and no murmur, flat, soft abdomen, no pedal edema.This is the ECG.

Figure 1 - 12L ECG

The 12L ECG revealed a regular wide QRS rhythm, tall T waves and the P waves are difficult to discern. The QRS and T wave segment seemed to merge or having a "sine" wave pattern. 

Laboratory work-up revealed creatinine of 3, BUN 62, bicarb 12 and K of 8. Patient was hydrated and NaHCO3, D50 and insulin, kayexalate were given. So, this patient has hyperkalemia from acute renal failure probable from diuretics (and patient was on ACEI and K supplement)

Progressive hyperkalemia produce distinctive sequence of events affecting the QRS (depolarization) and ST=T segments (repolarization). The normal serum potassium is between 3.5 and 5 mEq/L. The changes would be narrowing and peakng of the T waves ("tented" and "pinched" shape). Further potassium elevation will make P waves small and may disappear entirely. Continued elevation will produce intraventricular conduction delay (widening of the QRS), sine-wave pattern and asystole.

Reference:

Goldberger A. 2013. Goldberger’s Clinical Electrocardiography : A Simplified Approach 8Ed. Ph Elsevier

#307

Tall T waves due to hyperkalemia

An elderly hypertensive was admitted due to generalized weakness and nausea for a month and 2 weeks watery diarrhea.

This is the ECG. What do you expect to see in the lab of this patient?

This is sinus rhythm with tented T (tall and narrow) waves from V3 to V6.

Labs came back: WBC and PC - N, Hb 7.6 (L), Trop - 0.09, BG - 120, Na 135 (N), K 8.5 (H), CO2 9 (L), BUN 150's (H), Creatinine 19, UA showed pyuria and proteinuria. USD showed bilateal hydronephrosis.

So there was severe hyperkalemia due to renal failure (acute on chronic) prob obstructive uropathy with hypertensive nephrosclerosis. 

#216

Very wide QRS rhythm

An adult pt came in with h/o of HTN, DM 2 and end-stage renal disease is c/o dyspnea and change in sensorium.

Image 1

This is a VERY WIDE QRS rhythm. Consider toxic and metabolic causes.

The K  was 8.5. Because of the dyspnea, pt was intubated. Calcium gluconate, NaHCO3, insulin and kayexalte was given. Dialysis was also done. After a few days pt was discharged.

#420

Hyperkalemia in a patient with pacemaker

A 70 year old patient complaining of generalized swelling. 

This strip can can tell you 2 things: 

Image 1

-In V1 you can see the atrial spikes. This patient had an AICD. EF is in the 30's which could explain the low voltage ecg and poor R wave progression (cardiomyopathy).

-There is hyperkalemia as shown by a wide QRS and tall T waves in the precordial leads. (compare the 12L in the case and the 12L below when K was normal).

Image 2

The reason for the swelling was acute renal failure and the K was ~ 7.Calcium gluconate, glucose-insulin, sodium bicarb and kayexalate were given.

So, the 2 things that this strip can tell: cardiomyopathy - low voltage limb leads/poor R wave progression and hyperkalemia.

#115