Emergency Department Minute Quiz: Older Man Thrashing and Unresponsive

History: A man in his 60s is brought to the ED for thrashing around unconscious at a fast-food establishment. Bystanders say that he had been alert and normal five minutes earlier. Medics noted a run of v-tach for approximately 30 seconds.

Exam: Vital signs are normal except for a blood pressure of about 70 systolic. On arrival to ER the patient is unresponsive with agonal guppy breathing.

An EKG is done:

COMPUTER EKG READ:

1. Sinus rhythm
2. Intraventricular conduction delay
3. Possible right ventricular hypertrophy
4. Type 3 Brugada pattern

1) This ECG is pathognomonic for hyperkalemia. It can’t be anything else. It is wide and regular with no P-waves but is too slow for V-tach. There is ST elevation in V1, V2 which is a common STEMI mimic of hyperkalemia There are also Brugada-type T-waves in V1, V2 and narrow-peaked T-waves in the lateral leads. These are all known findings in hyperkalemia.

2) EKG analysis (Peer reviewed by Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): There are no convincing P-waves so this is not likely to be a sinus rhythm. It does appear regular and so could be ectopic atrial or junctional. There is an intraventricular conduction delay: the QRS is wide and was measured by the computer as 137 msec. There is also RV hypertrophy; the criteria for RVH are R wave in V1 >7mm tall, S wave in V1 <2mm, R/S ratio in V1 >1.0, QRS duration <0.12msec & axis 110-180°. All criteria are met except the first one. There is also right axis deviation (net positive in lead II and net negative in lead I)Finally there is a pseudo-STEMI pattern in V1-V2 that to me that looks like Brugada type 1

3) Case Conclusion: troponin-i was 0.07 and did not rise on repeat(99% URL <0.030: troponin-i immunoassay, Abbott laboratories). Potassium was 8.7 and there was also new-onset renal failure. The patient was treated for hyperkalemia and admitted to the ICU for emergent hemodialysis. The EKG findings all normalized once the potassium level normalized.

4) 1-Minute Consult (from the Emergency Medicine 1-Minute Consult Pocketbook) on the topic for this case:

4) Case Lessons: Always consider hyperkalemia in the differential diagnosis of new right axis deviation, new wide QRS or Brugada-like EKG changes.

5) Case Pearls:

• If the QT is long avoid Reglan, Compazine or Zofran. Instead use an antihistamine to treat nausea
• There is scant literature EKG changes from low phos; findings may include prolonged QT, PVC’s, STV and AFib.
• With DKA glucose is typically over 300, but can be lower or normal if the patient is on a flozin type medication.

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should. The entire document is long, but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from