This is a 53 yr old female, with significant history of DM II / ESRD on HD with Indwelling Catheter access who presented with fever and chills and was subsequently admitted for presumed sepsis. She was 3 days post dialysis and missed her session scheduled for today. On admission, EKG was taken and the following was found. Previous EKG's showed only Normal Sinus Rhythm. What is your interpretation and what abnormalities are we tipped off to? Look below for follow up EKG's and Answer.

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She was found to have a potassium level of 7.2 on her admission BMP which was tipped off by the increased amplitude and peaking of the T waves. Which also explained all the other abnormalites. This was read as:

Junctional Bigeminy, Left Bundle Branch Block, and Peaked T waves.

Notice how large the T waves look in comparison to the QRS complex. That is the tip off. The fact that the T waves in leads v4 dwarf the QRS and in v2-v3 are almost as large. Also, since previous EKG showed Normal sinus rhythm with no other abnormalities, the prolongation of the QRS to .168 sec (left bundle branch block) and the Junctional Bigmeny with no obvious atrial activity is now chalked up to the electrolyte abnormality. Check here for the what Hyperkalemia can do to the EKG, and for the criteria to diagnose a junctional rhythm and left bundle branch block.

This next EKG was taken 4 hours post admission, pre-dialysis.

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This was read as:

Junctional Rhythm, Left Bundle Branch Block, and Peaked T waves.

The findings of hyperkalemia are still present.

The following EKG was taken the next morning post dialysis with the Potassium now corrected on the BMP.

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Final Reading:

NORMAL SINUS RHYTHM!!!!!

Amazing! We hypothesized that the abnormalities were most likely due to her electrolyte abnormalities, but now with this EKG with the potassium normalized we have proven it.