The Ions Have It: Difference between revisions

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m (New page: {{NHJ| |mainauthor= '''A.A.M. Wilde, R.B.A. van den Brink''' |edition= 2005:11,428 }} Figure 1|thumb A46-year-old male was admitted to our emergency ...)
 
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{{NHJ|
{{NHJ|
|mainauthor= '''A.A.M. Wilde, R.B.A. van den Brink'''
|mainauthor= '''T.A. Simmers, A.A.M. Wilde'''
|edition= 2005:11,428
|edition= 2005:11,428
}}
}}
[[Image:Puzzle_2005_11_428_fig1.jpg|Figure 1|thumb]]
[[Image:Puzzle_2005_11_428_fig1.jpg|Figure 1|thumb]]


A46-year-old male was admitted to our emergency
A 46-year-old male was admitted to our emergency
room with dyspnoea. His medical history included
room with dyspnoea. His medical history included
congestive heart failure with a left ventricular ejection
congestive heart failure with a left ventricular ejection
Line 18: Line 18:


[[Puzzle 2005_11_428 - Answer|Answer]]
[[Puzzle 2005_11_428 - Answer|Answer]]
[[Image:Puzzle_2005_11_428_fig2.jpg|Figure 2|thumb]]
[[Image:Puzzle_2005_11_428_fig3.jpg|Figure 3|thumb]]
The ECG is remarkable due to the lack of P waves,
and the extremely broad QRS (merging directly into
the prominent T waves in rS complexes). A diagnosis of
severe hyperkalaemia should be considered immediately.
Laboratory work-up revealed the following relevant
findings: sodium 127 mmol/l, potassium 8.8 mmol/l,
creatinine 866 μmol/l, urea 63.4 mmol/l, and a
metabolic acidosis with a pH of 7.08 and serum lactate
4 mmol/l. Acute renal failure was diagnosed as the
cause, due to a combination of forward failure, high
dose of furosemide, spironolactone, in addition to
colchicine and an nonsteriodal anti-inflammatory drug
(NSAID) prescribed because of the patient’s gout,
compounded by the metabolic acidosis. The ECG in
figure 1 is a classic example of the effects of hyperkalaemia:
resting potential is reduced, partially inactivating
the sodium channels, reducing the depolarising
current and slowing atrial, AV and ventricular
conduction. Flattening and finally disappearance of
the P wave and broadening of the QRS complex result.
Life-threatening ventricular tachyarrhythmias with a
sinusoidal appearance may ensue in severe cases. Just
minutes after the ECG in figure 1, the ECG in figure
2 demonstrated onset of ventricular tachycardia.
Emergency measures were undertaken to lower the
serum potassium (i.e. correction of acidosis, insulin
and glucose iv, and calcium levulate iv). The patient
survived this episode; the ECG in figure 3 was taken
two days later at which time the serum potassium was
normal. He died several months later of progressive
heart failure.

Latest revision as of 14:08, 19 May 2010

Author(s) T.A. Simmers, A.A.M. Wilde
NHJ edition: 2005:11,428
These Rhythm Puzzles have been published in the Netherlands Heart Journal and are reproduced here under the prevailing creative commons license with permission from the publisher, Bohn Stafleu Van Loghum.
The ECG can be enlarged twice by clicking on the image and it's first enlargement
Figure 1

A 46-year-old male was admitted to our emergency room with dyspnoea. His medical history included congestive heart failure with a left ventricular ejection fraction of under 10%, type II diabetes, gout, hypothyroidism and morbid obesity. Physical examination was severely hampered by the patient’s weight (in excess of 230 kg), but revealed signs of right and left heart failure. The ECG on admission is shown in figure 1.

What diagnosis does it suggest, what further information do you need, and how should the patient be treated?

Answer

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