EKG Hyperkalemia And Digitoxic With Classic Clinical Findings

It's not everyday that you get a classic EKG with hyperkalemia (high potassium) and digitoxic findings.  Here's an example of an EKG sent to me by a reader and the story associated with these ECG findings.  It makes for a great learning opportunity.    This was a really sick lady with multiple medical problems who presented with a catastrophic decompensation of non cardiac origin.  She presented in a shock like state with multiorgan failure.

Her underlying conditions included  diabetes, chronic kidney disease, hypertension, atrial fibrillation  and CAD.  As far as the classic EKG hyperkalemia findings go, what you see  here is the widening of the QRS complex with the beginnings of a sinusoidal wave form and the  peaked T waves.  Both are classic EKG hyperkalemia changes.  A QRS complex normally has sharp defined peaks. As the potassium rises, EKG hyperkalemia changes force a longer and longer QRS into QT into T wave sinusoidal morph.  In this patient, the potassium was just under 9.  I would suspect at that level that the QRS would have been much wider and the sinusoidal wave form much more prominent.  The fact that it wasn't makes me think she probably ran borderline hyperkalemic before her catastrophic illness.

As for her digitoxic presentation, I was always taught that a digitoxic patient would  present with a junctional bradycardia.      That's how the case presented on my internal medicine boards as well.  But I know they can present with both tachy and brady rhythm changes.  In this case, her underlying atrial fibrillation was a slow ventricular response, despite her catastrophic shock like state.  That's probably the result of her increased digoxin level.  One thing you don't want to do in a patient with digoxin toxicity is to give calcium (which is what you want to do in a patient with critical hyperkalemia)  I don't remember the physiology behind it.   I just remember doing so can be highly proarrhythmic.  After her potassium and digoxin levels corrected, she converted to a sinus rhythm, which makes me think that the atrial fibrillation was also itself an EKG manifestation of her digitoxic presentation.  These are the things you train for and never forget as a hospitalist.

Make sure to visit the rest of my EKG collection.  

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