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Hyperkalemia Hyperkalemia (Example 1) Hyperkalemia (Example 2) Hyperkalemia (Example 3) Hyperkalemia (Example 4) Hyperkalemia before calcium bolus (Example 5) Hyperkalemia just after calcium bolus (Example 5) The ECG findings of hyperkalemia change as the potassium level increases. From earliest to latest the ECG findings include: 1) Peaked T waves best seen in the precordial leads, shortened QT interval, and sometimes ST segment depression. 2) Widening of the QRS complex occurs (usually requires a potassium level of 6.5 or greater). This frequently appears as in "intraventricular conduction delay" or IVCD which is characterized by a widened QRS complex of > 120 ms that does not meet the criteria for a left or right bundle branch block. Frequently an IVCD will look like a left bundle branch block in lead V1 with a rS complex or monomorphic S wave and it appears like a right bundle branch block in leads I and V6 with a broad, slurred S wave. CLINICAL PEARL: If you see an IVCD, think of hyperkalemia! 3) Decreased amplitute of the P waves, an increase in the PR interval, and bradycardia in the form of AV blocks occur as the potassium level exceeds 7.0. CLINICAL PEARL: Supportive measurements like fluids, pacing, and pressors do not work in the setting of hyperkalemia. You must treat the hyperkalemia first! 4) Absence of the P waves and eventually a "sine wave" pattern (see below) which is frequently a fatal rhythm.  CLINICAL PEARL:
Giving intravenous calcium is "cardioprotective" in the setting of
hyperkalemia. You will frequently see instant reversal of all
hyperkalemic ECG changes within seconds of administration. Calcium does not decrease the potassium
levels, so other therapy like bicarbonate or insulin is needed to do
this.
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