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{{Hyperkalemia}}
{{CMG}}; {{AE}} [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]


{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org]
==Overview==
==Overview==
Extreme degrees of hyperkalemia are considered a [[medical emergency]] due to the risk of potentially fatal [[arrhythmia]]s.  The EKG is an important tool in diagnosing hyperkalemia.  However, EKG changes do not always correlate with the degree of hyperkalemia.  Some of the EKG changes that can be seen associated with hyperkalemia include [[peaked T waves]] ([[T wave tenting]]), [[PR interval prolongation]], [[QRS complex widening]], absent [[P waves]], a sine wave pattern and [[sinus arrest]].
Extreme degrees of hyperkalemia are considered a [[medical emergency]] due to the risk of potentially fatal [[arrhythmia]]s.  The [[EKG]] is an important tool in evaluating a patient who has hyperkalemia as well as in diagnosing hyperkalemia.  However, [[EKG]] changes do not always correlate with the degree of hyperkalemia.  Some of the EKG changes that can be seen associated with hyperkalemia include [[peaked T waves]], [[PR interval prolongation]], [[wide QRS|QRS complex widening]], absence of [[P waves]], [[sine wave pattern]] and [[sinus arrest]].


==Pathophysiology==
==Electrocardiogram==
There appears to be a direct effect of elevated potassium on some of the potassium channels that increases their activity and speeds membrane repolarization. Hyperkalemia causes an overall membrane depolarization that inactivates many sodium channels. The faster repolarization of the cardiac [[action potential]] causes the tenting of the T waves, and the inactivation of sodium channels causes a sluggish conduction of the electrical wave around the heart, which leads to smaller P waves and widening of the [[QRS complex]].
* Elevated [[potassium]] level increases the activity of some [[potassium channels]] and speeds membrane [[repolarization]]. Hyperkalemia causes an overall membrane repolarization that inactivates many sodium channels. Changes in extracellular potassium disrupts the normal electrophysiology of the [[heart]] through the following mechanisms:<ref name="pmid8435272">{{cite journal| author=Freeman SJ, Fale AD| title=Muscular paralysis and ventilatory failure caused by hyperkalaemia. | journal=Br J Anaesth | year= 1993 | volume= 70 | issue= 2 | pages= 226-7 | pmid=8435272 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8435272  }} </ref><ref name="pmid3717152">{{cite journal| author=Szerlip HM, Weiss J, Singer I| title=Profound hyperkalemia without electrocardiographic manifestations. | journal=Am J Kidney Dis | year= 1986 | volume= 7 | issue= 6 | pages= 461-5 | pmid=3717152 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3717152  }} </ref>
** Prolongation of membrane [[depolarization]] that will cause peaked T waves
** Slower myocardial conduction that will prolong QRS interval and bradycardia
** Shortening of the [[repolarization]] time


===Moderate Hyperkalemia===
=== EKG Changes in Chronological Order ===
With moderate hyperkalemia, there is reduction of the size of the [[P wave]] and development of [[tent-shaped T waves]].


===Severe Hyperkalemia===
==== Peaked T Waves====  
Further hyperkalemia will lead to [[widening of the QRS complex]], and the QRS complex may ultimately become [[sinusoidal]] in shape (sine wave pattern).
* [[Peaked T waves]] are the earliest sign of hyperkalemia<ref name="pmid18235147">{{cite journal| author=Montague BT, Ouellette JR, Buller GK| title=Retrospective review of the frequency of ECG changes in hyperkalemia. | journal=Clin J Am Soc Nephrol | year= 2008 | volume= 3 | issue= 2 | pages= 324-30 | pmid=18235147 | doi=10.2215/CJN.04611007 | pmc=2390954 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18235147  }} </ref>.
* They occur when K > 5.5 meq/L.
* The differential diagnosis of this [[EKG]] change are [[bradycardia]] or [[stroke]]


==EKG FIndings==
====Interventricular Conduction Delay====
Specific findings include the following:
* It is observed when K > 6.5 meq/L
[[Image:Hyperkalemia2.jpg|left|400|Peaked T waves]]
* Interventricular conduction delay is reflected by [[Wide QRS|QRS widening]] that are inconsistent with [[LBBB]] or [[RBBB]].
{{clr}}
* Another manifestation of interventricular conduction delay is [[Prolonged PR|PR segment prolongation]].
* There is a modest correlation of the [[QRS]] duration with serum potassium level.
* As the serum potassium level rises, the [[QRS]] complexes may resemble sine waves.


===Tall, narrow, and peaked T waves===
====Loss of P Waves====  
* Earliest sign of hyperkalemia
* Decreased [[P wave]] amplitude occurs when K is > 7.0 meq/L with subsequent absence of [[P wave]]s when K is > 8.8 meq/L.
* Occurs with K > 5.5 meq/li
* The [[SA node]], continues to fire despite hyperkalemia and this results in atriventricular delay and responsible for absent p waves.le tlemia thanhe atr nduction. Thabsence onfused with [[sinus arrest|rest]]
* Differential diagnosis of this EKG change includes the T wave changes of [[bradycardia]] or [[stroke]].
* The absence of [[P wave]] along with [[wide QRS]] can be confused with [[ventricular tachycardia]].<ref name="pmid16572868">{{cite journal| author=Parham WA, Mehdirad AA, Biermann KM, Fredman CS| title=Hyperkalemia revisited. | journal=Tex Heart Inst J | year= 2006 | volume= 33 | issue= 1 | pages= 40-7 | pmid=16572868 | doi= | pmc=PMC1413606 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16572868  }} </ref><ref name="pmid22571204">{{cite journal| author=Petrov DB| title=Images in clinical medicine. An electrocardiographic sine wave in hyperkalemia. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 19 | pages= 1824 | pmid=22571204 | doi=10.1056/NEJMicm1113009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22571204  }} </ref>
* Prominent [[U wave]]s and [[QTc]] prolongation are more consistent with [[stroke]] than hyperkalemia.


[[Image:Hyperkalemia1.jpg|left|400px|Peaked T waves]]
==== Sinus Arrest with Accelerated Junctional Rhythm====
[[Image:Hyperkalemia.jpg|left|400px|Tall, symmetric, narrow based T waves in a hyperkalemic patient.]]
* It is observed when K>10meq/L.
{{clr}}
* Moderate or severe hyperkalemia can cause [[sinus arrest]]<ref name="pmid16792034">{{cite journal |author=Bonvini RF, Hendiri T, Anwar A |title=Sinus arrest and moderate hyperkalemia |journal=[[Annales De Cardiologie Et D'angéiologie]] |volume=55 |issue=3 |pages=161–3 |year=2006 |month=June |pmid=16792034 |doi= |url= |issn=}}</ref> causing accelerated junctional rhythm.dinn [[accelerated junctional rhythm|accelrated junctional rhythm]]<nowiki/>conditithe [[SA node|S nde]]<nowiki/>cal imp
* [[Accelerated junctional rhythm]] occurs when junctional [[pacemaker]] begin firing electrical impulses as a result of complete disruption of the sinoatrial conduction.<ref name="pmid16572868">{{cite journal| author=Parham WA, Mehdirad AA, Biermann KM, Fredman CS| title=Hyperkalemia revisited. | journal=Tex Heart Inst J | year= 2006 | volume= 33 | issue= 1 | pages= 40-7 | pmid=16572868 | doi= | pmc=PMC1413606 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16572868  }} </ref><ref name="pmid22571204">{{cite journal| author=Petrov DB| title=Images in clinical medicine. An electrocardiographic sine wave in hyperkalemia. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 19 | pages= 1824 | pmid=22571204 | doi=10.1056/NEJMicm1113009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22571204  }} </ref>


===Intraventricular conduction defect===
==== Sine Wave Pattern====  
* Observed when K > 6.5 meq/li
* As potassium level continues to rise, the [[QRS]] interval will continue to widen until it fuses with the [[T wave]].
* There is a modest correlation of the [[QRS]] duration with serum K
* The result of the fusion of the [[QRS interval]] and [[T wave]] is reflected by a [[sine wave pattern]].<ref name="pmid16572868">{{cite journal| author=Parham WA, Mehdirad AA, Biermann KM, Fredman CS| title=Hyperkalemia revisited. | journal=Tex Heart Inst J | year= 2006 | volume= 33 | issue= 1 | pages= 40-7 | pmid=16572868 | doi= | pmc=PMC1413606 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16572868  }} </ref><ref name="pmid22571204">{{cite journal| author=Petrov DB| title=Images in clinical medicine. An electrocardiographic sine wave in hyperkalemia. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 19 | pages= 1824 | pmid=22571204 | doi=10.1056/NEJMicm1113009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22571204  }} </ref>
* As the K rises, the [[QRS]] complexes may resemble sine waves
==== Ventricular Fibrillation====
* Generally the widening is diffuse and usually there is no resemblance of the morphology to that of either [[LBBB]] or [[RBBB]]
* Hyperkalemia can lead to [[ventricular fibrillation]], and subsequent [[asystole]], if the cardiac [[myocardium]] was not stabilized.<ref name="pmid16572868">{{cite journal| author=Parham WA, Mehdirad AA, Biermann KM, Fredman CS| title=Hyperkalemia revisited. | journal=Tex Heart Inst J | year= 2006 | volume= 33 | issue= 1 | pages= 40-7 | pmid=16572868 | doi= | pmc=PMC1413606 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16572868  }} </ref><ref name="pmid22571204">{{cite journal| author=Petrov DB| title=Images in clinical medicine. An electrocardiographic sine wave in hyperkalemia. | journal=N Engl J Med | year= 2012 | volume= 366 | issue= 19 | pages= 1824 | pmid=22571204 | doi=10.1056/NEJMicm1113009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22571204  }} </ref>
====Intraventricular Conduction Defect on EKG Before and After Treatment for Hyperkalemia====
[[Image:Ecg hyperkaliemie.jpg|500px|A patient's EKG with hyperkalemia.]]
[[Image:Ecg hyperkaliemie2.jpg|500px|Same patient's EKG during treatment.]]


===Decrease of the amplitude of the P wave or an absent P wave===
==== EKG Examples ====
* Decreased [[P wave]] amplitude occurs when the K is > 7.0 meq/li
Shown below is an [[EKG]] demonstrating [[peaked T waves]], loss of [[P wave]] and [[wide QRS complex]] depicting [[hyperkalemia]] <ref name="pmid1119378">{{cite journal| author=Bashour T, Hsu I, Gorfinkel HJ, Wickramesekaran R, Rios JC| title=Atrioventricular and intraventricular conduction in hyperkalemia. | journal=Am J Cardiol | year= 1975 | volume= 35 | issue= 2 | pages= 199-203 | pmid=1119378 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1119378  }} </ref>.
* [[P wave]]s may be absent when the K is > 8.8 meq/li
[[Image:Hyperkalemia2.jpg|center|500]]
* The impulses are still being generated in the [[SA node]] and are conducted to the ventricles through specialized atrial fibers without depolarizing the atrial muscle
----
* Moderate or sever hyperkalemia can cause [[sinus arrest]] <ref name="pmid16792034">{{cite journal |author=Bonvini RF, Hendiri T, Anwar A |title=Sinus arrest and moderate hyperkalemia |journal=[[Annales De Cardiologie Et D'angéiologie]] |volume=55 |issue=3 |pages=161–3 |year=2006 |month=June |pmid=16792034 |doi= |url= |issn=}}</ref>
Shown below is an [[EKG]] demonstrating [[wide QRS complexes]], tall [[peaked T waves]] an  fusion of the [[QRS complex]] and the [[T wave]].
[[image:Hyperkalemia123.jpg|center|500px|thumb]]
----
Shown below is an [[EKG]] demonstrating tall, narrow and [[peaked T waves]].
[[Image:Hyperkalemia1.jpg|center|500px]]
----
Shown below is an [[EKG]] demonstrating tall, narrow and [[peaked T waves]].
[[Image:Hyperkalemia.jpg|center|500px]]
<br clear="left" />
----
Shown below is an [[EKG]] demonstrating sine wave pattern depicting severe hyperkalemia.<ref name="pmid27067089">{{cite journal| author=Patton KK, Ellinor PT, Ezekowitz M, Kowey P, Lubitz SA, Perez M et al.| title=Electrocardiographic Early Repolarization: A Scientific Statement From the American Heart Association. | journal=Circulation | year= 2016 | volume= 133 | issue= 15 | pages= 1520-9 | pmid=27067089 | doi=10.1161/CIR.0000000000000388 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27067089  }} </ref>
[[Image:Sine_wave.jpg|center|500px]]
[[Image:Sine_wave_hyperkalemia.JPG|center|900px]]


===ST segment changes simulating current of injury===
 
* Have been labeled the dialyzable current of injury
----
===Cardiac arrhythmias: bradyarrhythmias, tachyarrhythmias, atrioventricular conduction defects===
Shown below are a series of [[EKG]] images demonstrating interventricular conduction defect before, during and after treatment of hyperkalemia.
* Occurs with severe hyperkalemia, not mild to moderate hyperkalemia
; Before treatment:
[[Image:Ecg hyperkaliemie.jpg|500px|center]]
; During treatment:
[[Image:Ecg hyperkaliemie2.jpg|500px|center]]
; After treatment:
[[Image:HK3.jpg|500px|center]]


==References==
==References==
{{reflist|2}}
{{reflist|2}}


{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 19:40, 30 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyamvada Singh, M.B.B.S. [2]

Overview

Extreme degrees of hyperkalemia are considered a medical emergency due to the risk of potentially fatal arrhythmias. The EKG is an important tool in evaluating a patient who has hyperkalemia as well as in diagnosing hyperkalemia. However, EKG changes do not always correlate with the degree of hyperkalemia. Some of the EKG changes that can be seen associated with hyperkalemia include peaked T waves, PR interval prolongation, QRS complex widening, absence of P waves, sine wave pattern and sinus arrest.

Electrocardiogram

  • Elevated potassium level increases the activity of some potassium channels and speeds membrane repolarization. Hyperkalemia causes an overall membrane repolarization that inactivates many sodium channels. Changes in extracellular potassium disrupts the normal electrophysiology of the heart through the following mechanisms:[1][2]
    • Prolongation of membrane depolarization that will cause peaked T waves
    • Slower myocardial conduction that will prolong QRS interval and bradycardia
    • Shortening of the repolarization time

EKG Changes in Chronological Order

Peaked T Waves

Interventricular Conduction Delay

  • It is observed when K > 6.5 meq/L
  • Interventricular conduction delay is reflected by QRS widening that are inconsistent with LBBB or RBBB.
  • Another manifestation of interventricular conduction delay is PR segment prolongation.
  • There is a modest correlation of the QRS duration with serum potassium level.
  • As the serum potassium level rises, the QRS complexes may resemble sine waves.

Loss of P Waves

  • Decreased P wave amplitude occurs when K is > 7.0 meq/L with subsequent absence of P waves when K is > 8.8 meq/L.
  • The SA node, continues to fire despite hyperkalemia and this results in atriventricular delay and responsible for absent p waves.le tlemia thanhe atr nduction. Thabsence onfused with rest
  • The absence of P wave along with wide QRS can be confused with ventricular tachycardia.[4][5]

Sinus Arrest with Accelerated Junctional Rhythm

Sine Wave Pattern

Ventricular Fibrillation

EKG Examples

Shown below is an EKG demonstrating peaked T waves, loss of P wave and wide QRS complex depicting hyperkalemia [7].

500
500

Shown below is an EKG demonstrating wide QRS complexes, tall peaked T waves an fusion of the QRS complex and the T wave.

Shown below is an EKG demonstrating tall, narrow and peaked T waves.

Shown below is an EKG demonstrating tall, narrow and peaked T waves.


Shown below is an EKG demonstrating sine wave pattern depicting severe hyperkalemia.[8]


Shown below are a series of EKG images demonstrating interventricular conduction defect before, during and after treatment of hyperkalemia.

Before treatment
During treatment
After treatment

References

  1. ↑ Freeman SJ, Fale AD (1993). "Muscular paralysis and ventilatory failure caused by hyperkalaemia". Br J Anaesth. 70 (2): 226–7. PMID 8435272.
  2. ↑ Szerlip HM, Weiss J, Singer I (1986). "Profound hyperkalemia without electrocardiographic manifestations". Am J Kidney Dis. 7 (6): 461–5. PMID 3717152.
  3. ↑ Montague BT, Ouellette JR, Buller GK (2008). "Retrospective review of the frequency of ECG changes in hyperkalemia". Clin J Am Soc Nephrol. 3 (2): 324–30. doi:10.2215/CJN.04611007. PMC 2390954. PMID 18235147.
  4. ↑ 4.0 4.1 4.2 4.3 Parham WA, Mehdirad AA, Biermann KM, Fredman CS (2006). "Hyperkalemia revisited". Tex Heart Inst J. 33 (1): 40–7. PMC 1413606. PMID 16572868.
  5. ↑ 5.0 5.1 5.2 5.3 Petrov DB (2012). "Images in clinical medicine. An electrocardiographic sine wave in hyperkalemia". N Engl J Med. 366 (19): 1824. doi:10.1056/NEJMicm1113009. PMID 22571204.
  6. ↑ Bonvini RF, Hendiri T, Anwar A (2006). "Sinus arrest and moderate hyperkalemia". Annales De Cardiologie Et D'angéiologie. 55 (3): 161–3. PMID 16792034. Unknown parameter |month= ignored (help)
  7. ↑ Bashour T, Hsu I, Gorfinkel HJ, Wickramesekaran R, Rios JC (1975). "Atrioventricular and intraventricular conduction in hyperkalemia". Am J Cardiol. 35 (2): 199–203. PMID 1119378.
  8. ↑ Patton KK, Ellinor PT, Ezekowitz M, Kowey P, Lubitz SA, Perez M; et al. (2016). "Electrocardiographic Early Repolarization: A Scientific Statement From the American Heart Association". Circulation. 133 (15): 1520–9. doi:10.1161/CIR.0000000000000388. PMID 27067089.


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