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23-47: Hyperkalemia

Maite A. Huis in ‘t Veld; Amal Mattu; R. Jason Thurman

ECG Findings

Findings are variable but tend to correlate with increasing serum potassium levels following the order below:

  • Peaked T waves, tented with a narrow base (may be > 10 mm high in precordial leads and/or > 6 mm in limb leads)

  • QRS complex widening

  • PR interval prolongation

  • Decreased P-wave amplitude

  • As potassium levels approach and exceed 8.0 mEq/L:

    • Indiscernible P waves

    • New bundle branch blocks or fascicular blocks

    • Sine wave appearance of QRS-T complex

    • VT, fibrillation, or asystole

Pearls

  1. Hyperkalemia is often missed on the initial ECG as it can produce nonspecific changes.

  2. Acute treatment for hyperkalemia includes insulin and glucose, sodium bicarbonate, and β-agonists in an attempt to drive potassium into the cell. Intravenous calcium may be used to stabilize the myocardium but has no effect on serum potassium levels. These are temporizing measures that must be followed by definitive treatment of the underlying problem, which may include the need for dialysis.

FIGURE 23.47A

Hyperkalemia (potassium of 7.1). (ECG contributor: R. Jason Thurman, MD.)

An E C G tracing with 12 leads from a patient with hyperkalemia.
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FIGURE 23.47B

Peaked T waves (arrow), widened QRS (double arrow), and subtle flattening of the P waves are seen in this patient with a serum potassium of 7.1.

An E C G tracing of lead V 4, consists of a wide, sharp peak, a narrow, sharp peak, and a sharp dip. A double-headed arrow is across the base of the dip. An arrow points to the top of the wide peak.
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FIGURE 23.48A

Severe Hyperkalemia—Sine Wave. (ECG contributors: Sam Parnell, MD, and Tracy Fennessy, MD.)

An E C G tracing with 12 leads from a patient with severe hyperkalemia. All leads, 1, 2, 3, a V R, a V L, a V F, V 1, V 2, V 3, V 4, V 5, and V 6, consist of an oscillating sine wave, with minor fluctuations along the wave.
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FIGURE 23.48B

Wide blunted QRS with sine wave appearance. No P waves are visible. Serum potassium was > 8 in this patient.

An E C G tracing with four leads from a patient with severe hyperkalemia. Leads V 1, V 2, V 4, and V 5 consist of an oscillating sine wave, with minor fluctuations along the wave.
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