FOAMed Question of the day 6 #FOAMedQOTD

Name 2 abnormalities on this ECG and a possible cause for these changes:



  1. 1) long QTc: congenital, medications (Antipsychotics, sotalol/amiodarone, TCA, macrolides)
    2) anterolateral ST depression (V2-5): subendocardial ischaemia, PE,

  2. Long PR – 1st degree block
    Widespread down sloping ST depression

    It’s gotta be digoxin toxicity?

  3. Victoria Stephen says:

    Prolonged QT, widespread ST depression. Possible cause, hypomagnesaemia, hypokalaemia

  4. Assuming normal calibration.
    Sinus rhythm, rate ~65 bpm, with single PVC (complex #5).
    Normal axis.
    PR prolongation.
    Apparent QT prolongation, 640+ms, corrected slightly longer.
    ST depression V2-6, I, II & ST elevation aVR.
    Prominent U waves best seenV2-6 & lead II with TU fusion. This is the cause of the apparent QT prolongation, this is really QU prolongation.
    Likely diagnosis given the ECG features is hypokalaemia, need clinical correlationon history & exam.
    Other differentials hypomag, given ST segments need to consider ischaemia but wouldn’t explain other ECG features.

  5. Chee Yong Chuan says:

    1) Sinus rhythm as evidenced by upright P waves in most limb leads. P wave inverted in aVR. P wave morphology normal. PR interval within normal range
    2) Axis normal, predominantly upright polarity in lead I and aVF
    3) QRS complexes regular, beating regularly at a rate of about 60 beats per minute
    4) A PVC is noted after the 4th sinus beat.
    5) QT interval is severely prolonged, using the eyeballing method, it is more than half the R-R interval
    6) Flattening of T waves can be seen in lead I and aVL
    7) Horizontal ST segment depression can be seen extending across precordial leads from V2-V6, the inferior leads II,III and aVF exhibit the same changes too
    8) R wave progression is good, no evidence of chamber enlargement or established infarct

    Impression: Changes observed likely due to electrolyte imbalance. Severe hypokalemia(with or without concomitant hypomagnesemia) can result in such prolonged QT/QU interval(what is observed might be due to fusion of T and a U wave).

  6. Malin Zachau says:

    I have familial hypokalaemic periodic paralysis and have been told I would be in trouble if my ECG looked like this. Could also be Anderson Tawil syndrome ( when potassium low rather than high?)

    I paralyse when my potassium is at 3.2 ( it is not the actual level that is of importance, it is the relative change ) . I currently take Diamox, Inspra, Amiloride and a Chlorvescent ( effervescent KCl).

    I am glad to see you all picked it up, but how would you treat me if I turned up with this ECG and paralysed?

    Kind Regards, Malin, exGP and Prehospital care practitioner, NZ

    • Hi Malin,
      Tough question, If you turned up with this ECG and paralysis we would be getting a prompt potassium level and looking at IV potassium depending on severity. as its unlikely we could give you any orally. that plus supportive care. not something I’ve had experience with.
      Ps, good luck with the novel.

      • malin zachau says:

        Hi, thanks for that, I will eventually finish my agricultural terrorism /spy thriller novel.
        The IV fluids to avoid in HKPP is anything with saline (sodium worsens paralysis) or glucose/dextrose ( insulin spike reduces potassium further),thus NG tube if oral cannot be tolerated tends to be safer and less likelihood of rebound hyperkalaemia .Potassium levels must be taken without tourniquet or any “fist pumping” since that can give a spuriously high reading in the region of 0.5. There is a very useful physicians resource on which has advice on emergency management and what medications to stay clear off etc.

        Hope you didn’t mind me hijacking your question, who knows , one day one of your followers might come across one of us ( incidence 1;100 000 but often misdiagnosed as CFS or somatoform disorder due to low level of awareness of this rare condition ) and might remember this.

        Bye for now , Malin

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