{"id":879,"date":"2020-10-16T13:25:38","date_gmt":"2020-10-16T20:25:38","guid":{"rendered":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/?page_id=879"},"modified":"2025-04-16T21:02:43","modified_gmt":"2025-04-17T04:02:43","slug":"ecg03042025","status":"publish","type":"page","link":"https:\/\/dhs.lacounty.gov\/emergency-medical-services-agency\/home\/emergi-press\/ecg03042025\/","title":{"rendered":"EMERGENCY MEDICAL SERVICES"},"content":{"rendered":"

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ECG OF THE MONTH \u2013 <\/strong>March \/ April 2025<\/p>\n

Case:<\/strong><\/p>\n<\/div>\n<\/div>\n<\/div>\n

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Paramedics respond to an industrial bakery for a traumatic injury. They arrive to find a 37-year-old male with no past medical history who states that while he was closing the bakery last night, a large piece of machinery fell and pinned his left leg. He was found several hours later by workers coming in for the morning shift who lifted the machinery off him and called 9-1-1. The patient reports severe pain in his left leg, as well as chest heaviness and dizziness. He has no significant bleeding, but his left leg below his knee is exquisitely tender with a mid-shin deformity, extensive bruising and swelling.<\/p>\n

Vital signs:<\/strong> \u00a0BP: 76\/44, HR: 30, RR: 30, EtCO2: 18, SpO2: 100% on room air<\/p>\n

An ECG is performed due to his complaint of dizziness and his bradycardia.<\/p>\n

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[\/vc_column_text][\/vc_column_inner][\/vc_row_inner][\/vc_column][\/vc_row][vc_row][vc_column][vc_tta_accordion][vc_tta_section title=”1. What is your interpretation of this ECG?” tab_id=”1594808836895-76766fb9-87a5″][vc_column_text css=””]Rhythm:<\/strong> Junctional bradycardia<\/p>\n

Other findings: Peaked T-waves, wide QRS (approx. 120 ms)<\/p>\n

No STEMI[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”2. Learn more about this ECG pattern” tab_id=”1594808836941-f3935ec1-1d1c”][vc_column_text css=””]Question: What provider impression is most appropriate for guiding this patient\u2019s treatment?<\/strong><\/p>\n

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  1. Cardiac Dysrhythmia – Bradycardia<\/li>\n
  2. Crush Injury\/Syndrome<\/strong><\/li>\n
  3. Hypotension\/Shock<\/li>\n
  4. Trauma<\/li>\n<\/ol>\n

    Explanation: Although all four provider impressions could apply, the immediate life-threatening issue that paramedics should address is the patient\u2019s hyperkalemia secondary to crush injury. In this young patient with no significant medical history and a history of crush injury, medics should assume the EKG changes and vital sign instability is secondary to hyperkalemia. Although the bradycardia provider impression includes hyperkalemia treatment, the important distinguishing factor is that the crush syndrome protocol calls for rapid infusion of normal saline as soon as possible. This is ideally done prior to release of the compressive force, however this was done prior to EMS arrival in this case.<\/p>\n

    Hyperkalemia occurs when blood levels of potassium are too high compared to the potassium levels in the blood. When blood potassium levels are too high, the heart cannot reset quickly as it usually does. The QRS widens because the cells cannot \u201creset\u201d and electricity flow slows down. It slows down the heart rate when it cannot reset effectively which is why patients become bradycardic and eventually develop asystole.<\/p>\n

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    \"\"[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”3. Causes of Hyperkalemia” tab_id=”1594808942323-7773516f-7109″][vc_column_text css=””]Hyperkalemia can be caused by many things. Potassium is common in many healthy foods and is normally excreted into urine by the kidneys. Both chronic and acute kidney injuries can limit the kidney\u2019s ability to excrete potassium. Acute kidney failure can be caused by severe dehydration, ingestion of toxic alcohols such as ethylene glycol (antifreeze), or lack of blood flow to kidneys from hypotension\/shock. Chronic renal failure develops in patients due to due to inherited or acquired diseases including uncontrolled diabetes or hypertension. As chronic kidney disease progresses in severity, the kidneys lose the ability to excrete potassium into the urine. Patients may demonstrate hyperkalemia if they are unaware of the severity of their chronic kidney disease, or if they have known end-stage renal failure but have missed their dialysis appointment(s).<\/p>\n

    In this case, hyperkalemia was most likely caused by crush injury to this person\u2019s leg. The massive tissue destruction caused by his leg being pinned for several hours led the crushed muscle cells to release potassium and other electrolytes into the blood stream; this directly raises the blood potassium levels. The crush muscle cells also release myoglobin which in high amounts can cause renal failure, so that the kidneys cannot properly clear potassium causing the blood levels to rise. The chart below lists “Critical Ischemic Time” for different body tissues – the time for which you can deprive the tissue of oxygenated blood through crush or other means, before the tissue death is unrecoverable. Partial cell lysis and release of potassium into the blood stream starts before this time and accelerates rapidly as the tissue dies.<\/p>\n

    \"\"[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”4. Hyperkalemia Treatment” tab_id=”1744859683902-d4fdc463-3eb9″][vc_column_text css=””]Treatment of hyperkalemia in the field has two priorities. Stabilizing the cardiac membrane and shifting potassium into cells and out of the blood stream. Stabilizing of the cardiac membrane is done by giving 1 gm of calcium chloride (10 mL slow IV\/IO push). You may see the ECG improve within seconds of medication administration; this may be repeated once if the ECG does not improve. Sodium bicarbonate and albuterol shift potassium from the blood into cells and prevent it from destabilizing the heart. Sodium bicarbonate 50 mEq (50 mL) can be given via slow IV\/IO push and repeated once. In contrast to the bradycardia protocol this can be done twice prior to base contact if ECG changes persist despite administration of calcium. Albuterol should be given continuously until hospital arrival.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”5. ECG Case Follow Up” tab_id=”1744859778340-4bb9a57e-effd”][vc_column_text css=””]The patient was treated with calcium chloride, albuterol, sodium bicarbonate, and normal saline during transport for suspected hyperkalemia. His HR improved and he arrived to the ED with a HR of 96 and blood pressure within normal limits. At the hospital, the patient received ongoing treatments for hyperkalemia and underwent several days of emergent dialysis while his kidneys recovered. His leg was amputated below the knee, but he left the hospital 2 weeks later for care and prosthesis training at a rehabilitation facility.[\/vc_column_text][\/vc_tta_section][vc_tta_section title=”6. Take-Away Points” tab_id=”1649114580797-ade0a487-f85f”][vc_column_text css=””]<\/p>\n

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    1. Always consider hyperkalemia in patients with ECGs showing wide QRS complexes or bradycardia; or in patients reporting missed dialysis.<\/li>\n
    2. Crush injuries may cause hyperkalemia, especially if several hours have elapsed since injury.<\/li>\n
    3. The electrical system of the heart is affected by hyperkalemia, administer calcium chloride ASAP in suspected cases of hyperkalemia.<\/li>\n<\/ol>\n

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      Thank you to Life in the Fast Lane (https:\/\/litfl.com\/hyperkalaemia-ecg-library\/<\/a>) for the ECGs.<\/p>\n<\/div>\n<\/div>\n

      [\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"

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