Minh Dao, MD
Brandon Fainstad, MD
- Identify peaked T-waves, loss of P wave and widening QRS as indicators of hyperkalemia
- Determine the appropriate initial interventions for severe hyperkalemia
Plan to spend 5 minutes familiarizing yourself ECG. Have the image pulled up on the presenting screen or monitor. Ask for a full read of the ECG. If the learner has not done so already, ask them to commit to a rhythm
Diagnosis: Irregular ventricular rhythm at rate ~60 with extreme QRS widening (~250ms) and peaked T-waves suggestive of hyperkalemia.
Teaching: Hyperkalemia is a relatively common and extremely high-risk complication of acute and chronic kidney disease. The earliest signs of hyperkalemia are “peaked” T-waves. This is often misunderstood to mean “big” T-waves. However, large T-waves are normal repolarization pattern for LVH and not necessarily suggestive of hyperkalemia. The characteristics of “peaked” T-waves worth noting are that the upstroke of the T wave becomes at least as steep as the down stroke and that the tip of the T is pointy. The subsequent signs of concerningly high potassium levels are loss of the P wave, increased ectopy, widening QRS, ST-elevations and ultimately severe ventricular dysrhythmias (sine wave, ventricular fibrillation and asystole).