What’s super-wide?

We’re going to try something new, and look at an interesting progression of EKG’s from the same patient.  Here’s the kick-off:

~60 y.o. woman with weakness

Did I forget to mention in the quiz she was too weak to go to her life-saving dialysis?  Oops, sorry about that.  I wanted to start with this EKG however to re-address hyperkalemia for our interns who missed out on a similar EKG from a few months ago.

As always, USE A SYSTEM.  A lot of the people who identified this as Vtach probably didn’t even look at the rate.  Note that the computer got the rate wrong.  It takes about 2 and a half big boxes to complete a cycle so it’s between 100 and 150 based on boxes.  If you used the Count The Complexes And Multiply By Six technique we talked about last week it’s right about 120.

Moving on to rhythm, it would be quite odd for a V tach to be 120.  This is however a VERY wide complex rhythm.  Last week we went over a wide complex tachycardia which was wide because of a baseline LBBB.  A quick look for P waves comes up empty however and it’s way too wide to be a simple LBBB in any case.   The take-home on this EKG is that the differential for VERY wide complex QRS’s starts with hyperkalemia.  Actually that differential starts with hyperkalemia, progresses through to hyperkalemia and while it probably doesn’t quite end with hyperkalemia, it comes pretty close.  Indeed the patient’s potassium did come back between 8 and 9, though I would not advise waiting for the potassium result to start Calcium.  For those who wanted to give amiodarone, I’m not sure what would happen if you gave amio to someone with a K of 8.5, but I can’t imagine it would be a good thing.

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