It won’t always be THAT wide

Let’s talk about things that are steep.  The Tetons for instance.

Sadly I was sitting at my desk sorting EKG’s last week when a friend sent me this pic of their morning

Other steep things?  Well, I’d say learning curves in intern year are right up there.  And maybe T waves in certain circumstances.  Let’s move on to the EKG:

~70 y.o. woman with difficulty breathing

The rate is slowish, right around 60, maybe a little less.  Are there P waves?  While in aVF and to a lesser extent in the lateral chest leads there is an initial small positive deflection that immediately slurs into the rest of the QRS, if we compare those deflections to the rhythm strips below we can comfortably say those are not P waves.  There aren’t P waves at all, I see no irregularity to suggest fine A fib so this is an escape rhythm of some sort.  The QRS is EXTREMELY wide.  Forget 3 little boxes for a wide complex LBBB, this is about 8 little boxes.  The rate of around 60 though would suggest a junctional origin.  Axis is very difficult to determine on this EKG.

The T waves are also huge, and basically reflections of the QRS (or of the Tetons) and are quite symmetric.  This is as close to a sine wave as you can get without your patient actually coding from Hyperkalemia (in this case K was about 9).  A potassium-poisoned conduction system could have junctional beats be uber-wide.

Takehomes from this EKG?  This one is a pretty classic K progression (peaked T waves, then widening of the PR, then loss of the P as the QRS widens, then sine wave, then asystolic arrest).  One of you described this “a five alarm fire,” apt for sure; this patient could code within minutes.  When QRS is really really wide, end-stage hyperkalemia has to be considered and generally treated empirically.  Remember though that not everyone will follow that progression, consider hyperK in every bradycardia.

Going back to the open, a wide-complex hyperK ekg was in the intern assessment, there were a lot more right answers on this one!

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