it’s not enough just to be cold

I mean we live in Michigan.  Being cold is a way of life.  Though this EKG comes from Illinois; Jane says hello to all of you!

20180101_cold hyperK
55 y.o. man presents unresponsive, mildly hypotensive.

The patient presented to Jane unresponsive and hypotensive with a temp that turned out to be 84’F.

Let’s look at the EKG.  Rate is 60-70.  P waves are subtle, I think I can convince myself that they’re present in the central chest leads.  This is a situation where if you’re unsure then you may want the tech to print a 12 lead rhythm strip; it looks like Jane’s institution gives her just a 1 lead rhythm strip instead of the 3 leads we get here.  If those are P waves then it’s really close to a first degree AV block.

Looking at the QRS, we see marked widening in V3-V5 with the Osborn wave present, frequently indicative of hypothermia.  Note that dig toxicity can look pretty similar.  The Osborn J point elevation makes it hard to evaluate for ST elevation.  V1 has a millimeter of up-coving J point elevation, but in the presence of the mildly widened QRS, I would probably allow that.  The baseline wanders a little bit in V3 and V4; this is another place where a 12 lead rhythm strip may give useful information to allow you to find a place with a clean baseline to really prove to yourself there’s no ST elevation.  I think what we’re seeing in those leads also relates to the Osborn waves however.

I told you that 2 abnormalities are present.  Most people guessed hypercalcemia for the 2nd.  However, hypercalcemia causes a shortened QT most commonly (which admittedly can lead to the appearance of ST elevation, but that’s because of the compression caused by the short QT).  I don’t see QT shortening in this EKG.  What we do see is some T wave peaking.  This patient’s potassium is a little over 7.  Couple that with DKA and some lactic acidosis to boot and you’ve got yourself one sick patient.  Jane initiated re-warming with a Bair hugger, warmed IV fluid, and bladder irrigation with warmed IV fluid and had his temp up to 90 by the time he was admitted to the ICU.

Take-homes from this hypothermic hyperkalemic patient?  First, Osborn waves often show up on written boards as part of a hypothermia question.  Next, patients can have multiple problems (or multiple fractures), once you’ve found one, you have to keep looking for the next!

1 comment on “it’s not enough just to be cold

  1. Alex Spiewak

    Is looking pointy enough to considered T waves peaked? I thought traditionally they need to be considered greater than 50% of the height of the QRS. Also, is it enough to have it in one lead, most leads, all precordial leads? Not trying to be cheeky, just recently had a discussion with Dr. Meyering and Trigger about this and I dont know what the right answer is.


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