Emergency Department Minute Quiz: Older Man Thrashing and Unresponsive

September 16, 2020

An unresponsive older man presents to the emergency department after bystanders report he was thrashing around unconscious at a fast-food restaurant.

History: A man in his 60s is brought to the ED for thrashing around unconscious at a fast-food establishment. Bystanders say that he had been alert and normal five minutes earlier. Medics noted a run of v-tach for approximately 30 seconds.

Exam: Vital signs are normal except for a blood pressure of about 70 systolic. On arrival to ER the patient is unresponsive with agonal guppy breathing.

An EKG is done:

COMPUTER EKG READ:

  1. Sinus rhythm
  2. Intraventricular conduction delay
  3. Possible right ventricular hypertrophy
  4. Type 3 Brugada pattern

What is the most likely diagnosis?

  1. Pulmonary Embolism
  2. Acute Coronary Syndrome
  3. Ventricular Tachycardia
  4. Hyperkalemia

1) This ECG is pathognomonic for hyperkalemia. It can’t be anything else. It is wide and regular with no P-waves but is too slow for V-tach. There is ST elevation in V1, V2 which is a common STEMI mimic of hyperkalemia There are also Brugada-type T-waves in V1, V2 and narrow-peaked T-waves in the lateral leads. These are all known findings in hyperkalemia.

2) EKG analysis (Peer reviewed by Dr. Stephen W. Smith of Dr. Smith’s ECG Blog): There are no convincing P-waves so this is not likely to be a sinus rhythm. It does appear regular and so could be ectopic atrial or junctional. There is an intraventricular conduction delay: the QRS is wide and was measured by the computer as 137 msec. There is also RV hypertrophy; the criteria for RVH are R wave in V1 >7mm tall, S wave in V1 <2mm, R/S ratio in V1 >1.0, QRS duration <0.12msec & axis 110-180°. All criteria are met except the first one. There is also right axis deviation (net positive in lead II and net negative in lead I)Finally there is a pseudo-STEMI pattern in V1-V2 that to me that looks like Brugada type 1

3) Case Conclusion: troponin-i was 0.07 and did not rise on repeat(99% URL <0.030: troponin-i immunoassay, Abbott laboratories). Potassium was 8.7 and there was also new-onset renal failure. The patient was treated for hyperkalemia and admitted to the ICU for emergent hemodialysis. The EKG findings all normalized once the potassium level normalized.

4) 1-Minute Consult (from the Emergency Medicine 1-Minute Consult Pocketbookon the topic for this case:

4) Case Lessons: Always consider hyperkalemia in the differential diagnosis of new right axis deviation, new wide QRS or Brugada-like EKG changes.

5) Case Pearls:

  • If the QT is long avoid Reglan, Compazine or Zofran. Instead use an antihistamine to treat nausea
  • There is scant literature EKG changes from low phos; findings may include prolonged QT, PVC’s, STV and AFib.
  • With DKA glucose is typically over 300, but can be lower or normal if the patient is on a flozin type medication.

6) OMI Manifesto: If you haven’t yet read the OMI manifesto, you should. The entire document is long, but everyone should know at least the basics of why current STEMI criteria miss about 1/3 of occlusion MI’s that would benefit from