Hyperkalemia electrocardiogram
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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 increases the activity of some potassium channels and speeds membrane repolarization. Hyperkalemia causes an overall membrane repolarization that inactivates many sodium channels. While the fast repolarization of the cardiac action potential causes the tenting of the T waves, 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.
Moderate Hyperkalemia
With moderate hyperkalemia, there is reduction of the size of the P wave and development of tent-shaped T waves.
Severe Hyperkalemia
Further hyperkalemia will lead to widening of the QRS complex, and the QRS complex may ultimately become sinusoidal in shape (sine wave pattern).
EKG Examples
Shown below is an EKG demonstrating peaked T waves depicting hyperkalemia.
Shown below is an EKG demonstrating wide QRS complexes, fusion of the QRS complex and the T wave and tall peaked T waves.
Tall, Narrow, and Peaked T waves
- Earliest sign of hyperkalemia
- Occurs with K > 5.5 meq/li
- Differential diagnosis of this EKG change includes the T wave changes of bradycardia or stroke.
- Prominent U waves and QTc prolongation are more consistent with stroke than hyperkalemia.
Shown below is the EKG demonstrating tall, narrow and peaked T waves.
Shown below is the EKG demonstrating tall, narrow and peaked T waves.
Intraventricular Conduction Defect
- Observed when K > 6.5 meq/li
- There is a modest correlation of the QRS duration with serum K
- As the K rises, the QRS complexes may resemble sine waves
- Generally the widening is diffuse and usually there is no resemblance of the morphology to that of either LBBB or RBBB
Intraventricular Conduction Defect on EKG Before and After Treatment for Hyperkalemia
Shown below are the series of EKG images before, during and after treatment:
- Before treatment
- During treatment
- After treatment
Decrease of the Amplitude of the P wave or an Absent P Wave
- Decreased P wave amplitude occurs when the K is > 7.0 meq/li
- P waves may be absent when the K is > 8.8 meq/li
- 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 [1]
ST Segment Changes Simulating Current of Injury
- Have been labeled the dialyzable current of injury
Cardiac arrhythmias: bradyarrhythmias, tachyarrhythmias, atrioventricular conduction defects
- Occurs with severe hyperkalemia, not mild to moderate hyperkalemia
References
- ↑ 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
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