Severe Hyperkalemia: Electrocardiographic Tips for Early Recognition Based on a Case Report


  • Jorge Gonzalez-Zuelgaray Chief, Services of Electrophysiology (Sanatorios de la Trinidad San Isidro and Ramos Mejia) and Director, Career of Specialists in Arrhythmias and Clinical Electrophysiology, University of Buenos Aires, Argentina
  • Patricio I. Frangi Hospital Médico Policial Churruca-Visca, Buenos Aires, Argentina
  • Damián A. Longo PA. Hospital Médico Policial Churruca-Visca, Buenos Aires, Argentina
  • Luisina B. Tosoni Medical student, University of Buenos Aires, Argentina
  • Adrian Baranchuk Kingston General Hospital, Queen´s University, Ontario, Canada



Hyperkalemia, Electrocardiography, Potassium, Renal Insufficiency, Acute, Metabolic Acidosis, Cardiorespiratory Arrest, Myocardial Infarction, Coronary Angioplasty, Ejection Fraction, Hypertension, Dyslipidemias, Atrial Fibrillation, Diabetes Mellitus, Type 2, Asthenia, Dyspnea, Insulin, Diuretics, Acid-Base Imbalance, Ventricular Function, Left, Emergency Treatment


Background: Rapid correction of severe hyperkalemia is mandatory to survival due to its induction of fatal cardiac arrhythmias. The electrocardiogram serves as the diagnostic tool that can provide insight into such fatal arrhythmias. We present two relevant alterations seen in an 84-year-old female patient with previous anterior myocardial infarction, angioplasty of the circumflex coronary artery, left ventricular ejection fraction of 35%, hypertension, dyslipidemia, paroxysmal atrial fibrillation, and diabetes.

The Case: The patient had 4-days with asthenia, adynamia and dyspnea. Lung auscultation showed bilateral base rales with cardiomegaly and interstitial edema identified on chest x-ray. Lab work revealed severe metabolic acidosis, increased plasma urea, creatinine, and severe hyperkalemia (7.9 mEq/liter) considered secondary to acute renal failure. Treatment was initiated with 0.9% sodium chloride, bicarbonate, ASA diuretics and polarizing solution (insulin), resulting in a reduction of hyperkalemia to 6.1 mEq/liter. The patient suffered a cardiorespiratory arrest with recovery and needed intubation and dopamine for hemodynamic support but died 15 hours after admission.

Conclusion: The electrocardiographic findings characteristic of severe hyperkalemia were: (i) regular rhythm (cycle length 920-950 ms) without discernible P-waves, which may have a junctional or ventricular origin and less probably could be a manifestation of sinoventricular conduction (preferential conduction from the sinus node to the AV node through specialized tracts without activation of the atrial cardiomyocytes), and (ii) sine wave morphology (markedly wide QRS, absence of ST-segment and broadly based T-waves). These electrocardiographic features, typical of hyperkalemia exceeding 7.0 mEq/liter, are harbingers of malignant arrhythmias and should prompt immediate therapy.


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The image displays four segments of an electrocardiogram (ECG) titled "Initial 12-Lead ECG Indicative of Severe Hyperkalemia." Each segment shows a tracing of heart rhythm and electrical activity. The rhythm is regular, but the ECG demonstrates a sine-wave pattern, a sign often associated with severe hyperkalemia. This pattern includes extremely wide QRS complexes, an absence of a discernible ST-segment, and broadly based T-waves, which are characteristic changes in the heart's electrical pattern when potassium levels are critically high. The visual is a clinical representation commonly used by healthcare professionals to diagnose and assess the severity of hyperkalemia.




How to Cite

Gonzalez-Zuelgaray, J., Frangi , P. I., Longo, D. A., Tosoni, L. B., & Baranchuk, A. (2024). Severe Hyperkalemia: Electrocardiographic Tips for Early Recognition Based on a Case Report. International Journal of Medical Students, 12(1), 96–99.