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!
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!