All ECG 32
- Sinus bradycardia
- 3rd degree atrioventricular (AV) block
- Ventricular escape
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.