EKG Interpretation: Dr. Sosa’s EKG from the CCU

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25 y/o woman presents c/o weakness over the past few days. She has no PMH and takes no medications. She has a previous EKG that was normal.  Based on the chief complaint how would you interpret this EKG?



  • sannman

    NSR @ 75, no ST elevations, T wave abnormalities. PR normal, QRS narrow. QT prolonged (QTC = 600/square root of R = 670?)…unless these are U waves, which could mean hypokalemia. Is she vomiting/bulimic? Using laxatives or having lots of diarrhea?

  • andrewchertoff

    HypoK and HypoMag both require a follow up, “but why?”
    R in AvR + prolonged QT, age, lack of hx etc. makes me suspicious for TCA OD, but some abx will do it too (and many other drugs, but just going on common things).

  • mmegue01

    I agree with Allen as well as I think there are U waves present. I think TCA is a good thought but I would expect to see a prolongation of the QRS more so than the T wave alone…as it is a dysfunction of sodium channels.

    • alvarezzy

      agree. in tca, qtc prolongs later. it’s really the height of the terminal R on avR that’s predictive of seizures and the width of the QRS (>100 instead of 120) for prediction of seizures and cardiac dysrhythmias.. again, they’re usually tachy/altered. the trick is to push bicarb and just like pushing calcium in hyperK patients, the qrs will narrow and the height of the terminal R on avR will go down. This will prompt the bicarb gtt tx. this is not tca causing the u waves/qtc prolongation/weakness.

  • alvarezzy

    what’s the answer??
    my two cents. agree with u waves/hypok. hypokalemic periodic paralysis can cause this. terminal R on avR is a red herring or pt may be on TCA. TCA toxic are tachycardic/altered. would not give bicarb on this, especially given concerns for hypoK, which will drive K down even further.. I’d give K/Mag together, although if periodic paralysis is being considered, po (liquid) k is sufficient. send TSH.

    we see lots of hypoK in cali because of our proclivity for meth use, but rarely saw meth (if ever) in the bronx.

  • edgardososa

    Sorry fellas, I thought the admins would post the answer that I submitted originally. Anyway, you guys nailed it.

    “This patient had hypokalemia.

    The EKG shows sinus rhythm with a normal axis.

    It shows ST depressions in some leads, QT prolongation, T wave flattening, and large U waves. Many now believe that what we actually see is a T-U fusion wave, or a bifid T wave, rather than a true QT prolongation. In any case, this degree of QT prolongation increases the risk of ventricular tachycardia and torsades de pointes.

    Other possible findings include: P wave enlargement, PR prolongation, QRS widening, ST depressions, and T wave inversions.

    Hypokalemia is often caused by poor diet and/or GI fluid losses. But it would be important to exclude other electrolyte abnormalities, family history of long QT syndrome, and any possible medication/drug toxicity (including diuretics, hypoglycemics, antipsychotics, etc.), among other causes.”

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