ECG in Electrolyte Abnormalities

The faces of ECG series

Potassium
Serum potassium level may be deceiving
o Acute changes are likely to lead to ECG changes o Chronic changes often result in no or minimal ECG changes

Correlation between potassium level and ECG changes is unreliable Sensitivity in detecting hyperkalaemia is low

Wrenn KD, Slovis CM, Slovis BS. The ability of physicians to predict hyperkalemia from the ECG. Ann Emerg Med 1991;20:1229-32.

Case Example
A 17yo girl is known to suffer with anorexia nervosa, and purgative misuse, presented in ED as she complained she had felt very weak, and had not been able to get out of bed.

Case Example
A 17yo girl is known to suffer with anorexia nervosa, and purgative misuse, presented in ED as she complained she had felt very weak, and had not been able to get out of bed.

Case Example
A 17yo girl is known to suffer with anorexia nervosa, and purgative misuse, presented in ED as she complained she had felt very weak, and had not been able to get out of bed.

Potassium 1.8mmol/L

Hypokalaemia
A B C
T U

D
T U

E
T U

F
U

Hypokalaemia
Large P wave T wave flattening Prominent U wave

ST depression

Hypokalaemia
PR prolongation QTc prolongation T wave often merges with U wave Increased risk of VT

Case Example
62yo Maori woman with DMT2. She is on dialysis for CKD. 24hrs worsening nausea and vomiting. She missed one session as she briefly visited family in New Zealand.

Case Example
62yo Maori woman with DMT2. She is on dialysis for CKD. 24hrs worsening nausea and vomiting. She missed one session as she briefly visited family in New Zealand.

Case Example
62yo Maori woman with DMT2. She is on dialysis for CKD. 24hrs worsening nausea and vomiting. She missed one session as she briefly visited family in New Zealand.

Potassium 8.1mmol/L

Case Example
53yo man DMT1, CKD on dialysis. GCS 10. D2 post dialysis next session tomorrow. BSL >38mmol/L. Dry gangrene of toes and middle finger.

Case Example
53yo man DMT1, CKD on dialysis. GCS 10. D2 post dialysis next session tomorrow. BSL >38mmol/L. Dry gangrene of toes and middle finger.

Case Example
53yo man DMT1, CKD on dialysis. GCS 10. D2 post dialysis next session tomorrow. BSL >38mmol/L. Dry gangrene of toes and middle finger. K 8.6mmolL

Hyperkalaemia
Flat P wave Increased PR Wide QRS Peaked T wave

Hyperkalaemia
Sine wave appearance

Hyperkalaemia
Increased amplitude and peaking of T wave QRS prolongation PR prolongation P wave flattening Loss of P wave Sine wave appearance

Case Example
A 56yo woman has recently had a bout of viral gastro she had thyroidectomy 3 weeks ago. She is fatigued, has muscle cramps in the arms and tingling in the toes.

Case Example
A 56yo woman has recently had a bout of viral gastro she had thyroidectomy 3 weeks ago. She is fatigued, has muscle cramps in the arms and tingling in the toes.

Hypocalcaemia
QTc prolongation Ca deficiency Prolonged QTc interval

Hypocalcaemia
Terminal T wave inversion

Hypocalcaemia
QTc prolongation ST segment prolongation P wave normal PR interval normal Rate usually not affected

Case Example
A 63yo Lao man with lung cancer. He is complaining of anorexia, nausea, poliuria and polydipsia. He is constipated too.

Hypercalcaemia
QTc shortening Biphasic T wave

Osborn wave

Hypercalcaemia
P and T waves usually unaltered Ventricular fibrillation may occur in severe hypercalcaemia QT interval correlates with severity of hypercalcaemia

The End