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DIAGNOSIS: Hyperkalemia, sinus tachycardia, left axis deviation. The hyperkalemia has resolved in the second tracing . EXPLANATION: The slight sinus tachycardia, rate 108, and the mild left axis deviation, minus 45 degrees, require no discussion. The earliest sign of hyperkalemia is the development of tall, thin, `pinchbottomed' T waves. These may be subtle and are best appreciated in the first tracing in leads V3 and V4. Left untreated, the P-R segment becomes prolonged, the ST segment becomes depressed, and the QRS lengthens. Later the P waves disappear and the QRS continues to widen supposedly because the elevated potassium delays the spread of electrical depolarization through the myocardium. Ultimately, V-fib occurs. In this case, that of a 42 year old anorexic female, the K was 6.7 and the patient was asymptomatic other than mild dehydration. After 24 hours of treatment with bicarbonate, glucose, insulin, and a potassium binding resin, the K was 4.6 and the T waves have normalized. Editor: Sol Nevins MD FACEP. Faculty, Emergency Medicine Residency, Morristown Memorial Hospital, Morristown, N.J. |
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