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What’s the Diagnosis #15

An elderly patient presents with leg weakness over the prior two days. The day of presentation he also notices pain in his upper back which seems to be fairly persistent. His medical history includes diabetes and renal failure. He was dialyzed the afternoon prior to his presentation and his glucose was 264. The patient’s daughter stated that he “wasn’t acting himself.”
The patient’s physical exam was fairly normal. Perhaps a little weakness in his legs, but he still moved all extremities.
His current EKG (dark background) and another EKG faxed from a different hospital done six months earlier (light background) are shown below. You can click on them for larger images. What’s the diagnosis and what’s the next step?
I’ll post the answer underneath the EKGs in a couple of days.

Previous EKG.

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Answer:  Severe Hyperkalemia

The patient’s potassium was 7.9.

The history of being dialyzed the day before his presentation confounded the picture.
The EKG was worrisome enough that the patient was initially labeled as an acute MI and the cath lab was activated. Then one of the docs noted that there were no P waves and that the T waves were narrow and peaked which was consistent with a picture of hyperkalemia. The dialysis center was contacted and stated that the patient only had an hour of dialysis the day before his presentation because they were having trouble with his shunt. The dialysis center contacted the patient’s doctor at another facility whose colleague faxed a copy of an old EKG to the ED. A repeat EKG done 20 minutes later showed no further changes.
After receiving calcium, dextrose, insulin and albuterol, the patient’s EKG showed substantial improvement. The post-treatment EKG was performed 20 minutes after receiving the medications. Serial cardiac enzymes remained normal.
Aortic dissection is known to cause ST elevations in V1 and V2, but couldn’t find a report of a patient having such findings in the absence of chest pain.

EKG post treatment.

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19 comments

  1. Do you have his electrolyte values? I’m thinking specifically of K+.

  2. Am I missing something, or does this person earn a trip to the cath lab?

  3. Can we get an US to eval for dissection?

  4. Hypercalemia can explain the ECG changes and the muscle weakness. In the context of acute back pain, I would guess a vertebral crush fracture secondary to multiple myeloma.

  5. midwest em resident

    st elevation v1-v2 with std in 1, and as pat alluded, prominent twaves. I would think cath lab activation. pt is elderly, dm, atypical presentation isn’t that uncommon

  6. I’m with Pat. He needs glucose, insulin, Kayexalate and a call to his nephrologist.

  7. I’m not convinced that this is hyperkalemia. I would get a stat K level, but I’m more concerned for aortic dissection with his story and ST elevation in V1-V2. You can also see a similar pattern with large PEs. And of course this could be a STEMI.

  8. I’m adding a third vote for HyperK+, a classic mimic of “spetal” STEMI. Early Tx w/ calcium gluconate, albuterol, and insulin/glucose.

  9. Hyperkalemia. Needs dialysis

  10. LV aneurysm. S/p previous MI.

  11. I’m with VinceD

  12. Aortic dissection. LE weakness from anterior spinal cord ischemia (artery of Adamkew…however it is spelled). Upper back pain classic for dissection. ST elevations due to dissection into coronary artery.
    That would be a big ass dissection, though.

  13. dilaudid distributor

    Aortic aneurysm with extension into the carotid arteries. Not hyper K given the recent dialysis, and no peaked t-waves. Taught once the criteria for peaked t-waves was if you would sit on them or not. Would sit on all but maybe V3.

    • I’ve given a person 5hrs dialysis one night, and spent the next afternoon dialysing that exact same patient in coronary care. Not saying this is hyperkalaemia (haven’t had to read an ecg since I finished uni), however it’s not safe to rule out anything based on recent dialysis. You don’t get diabetic nephropathy from being compliant.

      • dilaudid distributor

        And I’ve seen, and I’ve seen, and I’ve seen dialysis patients skip for weeks and be ok. Can’t discount the other symptoms. I did throw in other support with the ekg. Go straight for the zebra on limited data, should have seen that right away. Fairly similar to the retrospectroscope mentality we all seem to live in now.

      • Haha, he’s eating is words now. HyperK is clearly NOT the zebra diagnosis.

  14. PS. WC…dialysis unit was using a shunt?? What century is this! ;p

  15. Just curious, what was his K+ value?

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