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• W4386584395 abstract "Figure: ECG, cardiology, hypokalemiaFigureFigureAn older woman presented to the ED with generalized weakness. She and her family said she had not had a fever, but she had a history of frequent urinary tract infections. They also said she had no syncope, palpitations, pain, shortness of breath, cough, or other symptoms. Her vital signs were normal, and an ECG was done (shown). The computer read it as an atrial pacemaker and an anteroseptal MI, probably recent, and highlighted the diagnosis: acute MI. What is the most likely cause of the ECG findings in this patient? Hypokalemia, pulmonary embolism, acute coronary syndrome, or hypocalcemia? The ECG showed biphasic T-waves and significant U-waves in the precordial leads. It also showed flat and nonspecific T-waves in the inferior leads and a prolongation of the QT or QU interval. These findings are suspicious for hypokalemia, although down-then-up T-waves are more common with hypokalemia than the up-then-down T-waves seen here. Dr. Smith was sent this ECG with no clinical info, and replied, “This ECG screams hypokalemia.” His additional lessons: Hypokalemia does not actually produce down-up T-waves as is often taught; it actually mimics down-up T-waves because it can cause ST depression followed by an upward U-wave. Hypokalemia can also cause apparent QT interval prolongation that is impossibly long, and it is usually actually a QU interval when the QT is impossibly long. Another common feature of hypokalemia on this ECG that is nearly pathognomonic are the long, scooped ST (really SU) segments. The correct answer, of course, is hypokalemia. U-waves, nonspecific T-waves, and long QT in a patient with generalized weakness is likely to be hypokalemia. The clinical presentation was less suggestive for pulmonary embolism, though that can cause flat or nonspecific T-wave changes, but is unlikely to cause U-waves. The clinical presentation fits for acute coronary syndrome, and up-down T-waves fit ACS, but U-waves are unlikely (but possible) in ACS. The clinical presentation was less suggestive for hypocalcemia, though that can cause flat or nonspecific T-wave changes and prolonged QT, but it is unlikely to cause U-waves. The patient's troponin-i was 0.08 ng/L both times it was taken four hours apart (99% URL <0.030: troponin-i immunoassay, Abbott Laboratories). Her potassium was also low at 2.8 mmol/L, and the magnesium was normal, but evidence of an ongoing UTI was present. Hypokalemia can cause many varied ECG findings and the degree of the abnormalities can vary significantly with the degree of hypokalemia. The findings on this ECG are more pronounced than one would typically expect with a potassium of 2.8. More severe ECG findings may be more likely when other electrolyte abnormalities are present or when the electrolyte abnormality develops more acutely. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Dr. Pregersonis an emergency physician with Palomar Health in San Diego. He is the author of Emergency Medicine 1-Minute Consult, the 8-in-1 Emergency Department Quick Reference Guide, the A to Z Emergency Pharmacopoeia & Antibiotic Guide, Don't Try This at Home, and Think Twice: More Lessons from the ER. Follow him on Twitter@EM1MinuteGuru, and visit his website athttps://em1minuteconsult.com. Read his past columns athttp://bit.ly/BradyCardiaEMN. Dr. Smithis emergency medicine faculty with Hennepin Healthcare, a professor of emergency medicine at the University of Minnesota School of Medicine, and the editor of Dr. Smith's ECG Blog. (https://bit.ly/306xAeq). Follow him on Twitter@smithecgblog." @default.
• W4386584395 created "2023-09-11" @default.
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• W4386584395 date "2022-05-01" @default.
• W4386584395 modified "2023-09-29" @default.
• W4386584395 title "BradyCardia" @default.
• W4386584395 doi "https://doi.org/10.1097/01.eem.0000831232.82848.7a" @default.
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