Treatment of hyperkalemia is one of those “must memorize” as opposed to “must know where to find” algorithms. An illustrated review of the ECG changes seen in hyperkalaemia with multiple high-quality 12-lead ECG examples.
The goal of treatment is to prevent cardiac arrhythmia, then lower serum potassium. Existing evidence does not support the use of bicarbonate for inducing intracellular shift in treating acute hyperkalemia [3].Kayexalate is an exchange resin used to bind potassium in the intestine when given orally. The order of ECG changes of hyperkalemia have been defined in the experimental setting, but no uniform order has been documented in animal models [1].
It is well known that if the baseline ECG is “abnormal” at baseline, some changes may not be as evident…so to make the blanket statement, you would actually need to see the 87 ECGs, which you are correct are not shown in the study.
I just think meticulous attention to wording and implications of diagnostic measures and therapeutic interventions is essential when dealing with this particular topic that is so important to emergency providers.1. There are five ECG/EKG changes/groups of changes associated with hyperkalemia … Thereafter, emergent therapies for lowering potassium levels are nebulized or inhaled salbutamol and/or IV insulin-and-glucose [2]. “Sensitivity” will obviously be far less IF the baseline ECG is abnormal.
If you’re looking for Dr. Morton’s review, please check back on Thursday, September 25, 2014. Minimal side effects and not expensive.
The two concerns with Kayexalate are its ineffectiveness in lowering serum potassium and its potential toxicity. It produces predictable changes on the ECG/EKG.
Electrophysiologic basis of ECG changes: In patients with mild hyperkalemia, potassium conductance (IKr) through potassium channels is increased, which tend to shorten the AP duration and on the ECG causing tall tented T waves. Considering the above, are there studies which show the relationship between s. potassium levels, the presence of ECG changes & cardiotoxicity. As for the conclusion made…it was the conclusion of the author.2. Therefore if a patient has a s. potassium of 6.5 but the ECG is normal, can we be more cautious before initiating treatment for the hyperkalemia?
Increased amplitude and width of the P wave; Prolongation of the PR interval; T wave flattening and inversion; ST depression; Prominent U waves (best seen in the precordial leads) Apparent long QT interval due to fusion of the T and U waves (= long QU interval) This has been the subject of a useful review [3]. We don’t know what “normal” and “abnormal” really mean in these 87 cases. […]
I’m fine with presumptive treatment until serum values come back when there is high clinical suspicion of hyperkalemia. Hyperkalemia may result in a progression of EKG changes including peaked T waves and QT interval shortening, PR and QRS interval prolongation, and finally a sine wave appearance.
ON the contrary – the combination of: i) serum K+ value – PLUS ii) one or more ECGs on the patient PLUS – the clinical context in which you assess i) + ii) are EXCELLENT for providing indication of whether or not emergency treatment measures for hyperkalemia are indicated – realizing that at time close follow-up and serial values of assessment tests will be needed to provide the full answer.THANK YOU for your receptivity of my constructive comments. For the sensitivity comment…point taken. In 2016 this Canadian blog brought its content to CanadiEM.CanadiEM aims to improve emergency care in Canada by building an online community of practice for healthcare practitioners and providing them with high quality, freely available educational resources.Join our community of educators by submitting a blog post, opinion piece, chalk talk, or lecture. With severe hyperkalemia, effect on RMP becomes prominent. TY.Hi Salim – THANK YOU (as always!)
)A Cochrane review concluded that, when ECG changes due to hyperkalemia are present, IV calcium is effective in preventing deterioration [2]. ):
Putting it another way, say we have 2 patients, both with a s. potassium of 6.5 mEq/l. Effects of hypokalaemia on the ECG. Posted by IkaN (Nakeya Dewaswala-Bhopalwala, M.D.) Sharpening up your wording may be all that is needed. That said – I do NOT agree with at least 2 of the two generalized conclusions you draw:i) Your Statement – “The ECG is not a sensitive method to detect hyperkalemia”.
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