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All ECG 32

Sinus bradycardia
3rd degree atrioventricular (AV) block
Ventricular escape
Hyperkalemia

This is quite an unusal ECG. The QRS morphology is unlike anything normally seen. Because it is upward concordent — that is, all directed upward — in the precordial leads, which is one of the Brugada criteria for a ventricular rhythm, a ventricular origin is suspected. This ECG occured in the setting of a potassium level of 8.2 mEq/L, which is very high. A “sine wave” pattern subsequently ensued; thus this ECG change was a precursor to the classic “sine wave” of hyperkalemia; a detailed review of the ECG changes with hyperkalemia can be found at the relevent link below. It is also important to note, in the setting of a ventricular rhythm, ischemia is difficult to diagnose. This ECG has ST segment elevation in the inferior leads with reciprocal depression — suspicious for an inferior myocardial infarction, but that was not the case in this scenario. Notice there are no Q waves in the inferior leads that would likely be present in the setting of such an extensive MI.

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sinus bradycardia

atrioventricular block