A 53yrs with diabetes since 5yrs and development vomiting 5months back and detected renal failure and put on dialysis since then.
ECG-was taken when he presented with tachypnoea and respirator rate of 38 per min following morning dialysis
[17/07/20, 3:04:28 PM] MBBS 2016 student: sir is this ecg with heart block And st elevations in chest leads
[17/07/20, 4:32:11 PM] Post residency PG 1: What kind of heart block is this?
[17/07/20, 4:32:32 PM] Post residency PG 1: Please circle the areas you feel is showing ST elevation
[17/07/20, 4:33:55 PM] MBBS 2016 student: 1 st degree

[17/07/20, 4:34:44 PM] MBBS 2016 student: St elevations
[17/07/20, 4:43:24 PM] Post residency PG 1: What features of first degree (SA or AV block) do you notice? Please elaborate
[17/07/20, 4:44:01 PM] Post residency PG 1: Does it satisfy the definition of ST elevation?
[17/07/20, 4:54:55 PM] MBBS 2016 student: Av block
[17/07/20, 4:55:34 PM] MBBS 2016 student: PR interval increase

[17/07/20, 5:01:46 PM] Post residency PG 1: Is it consistent in all leads and all complexes?
[17/07/20, 5:02:11 PM] Post residency PG 1: That's the T wave 😅
[17/07/20, 5:02:22 PM] MBBS 2016 student: Oh
[17/07/20, 5:02:39 PM] MBBS 2016 student: I always get confused with p and t waves sir
[17/07/20, 5:02:44 PM] MBBS 2016 student: 😬
[17/07/20, 5:03:19 PM] Post residency PG 1: Fair enough. In this ECG the p waves are sparse
[17/07/20, 5:03:26 PM] MBBS 2016 student: Ok sir
[17/07/20, 5:03:51 PM] MBBS 2016 student: What is this ecg sir?
[17/07/20, 5:06:34 PM] Post residency PG 1: Check out the second EcG of the same patient taken few seconds later just now shared in the group
[17/07/20, 5:06:53 PM] MBBS 2016 student: Ok sir
MBBS 2016 student:is this rbbb
This is second ECG taken few seconds later
[17/07/20, 5:47:59 PM] Post residency PG 1: It's the rbbb pattern although that's not the diagnosis 👍
[17/07/20, 5:53:16 PM] MBBS 2016 student: Ok sir
[17/07/20, 5:53:52 PM] MBBS 2016 student: Sir y is there so much difference within few secs
MBBS 2016 Student 2:"The spectrum of electrocardiographic changes seen with hyperkalemia is known to progress gradually with increasing serum levels of potassium. Initial changes are limited to peaked T waves and QT shortening, which subsequently progress to prolonged QRS/QT intervals, and finally sinus arrest, sinus bradycardia and asystole. We report a unique case of severe sinus bradycardia with atrial bigeminy and junctional rhythm in the setting of moderate hyperkalemia, a rarely reported electrocardiographic finding."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6973538/
[17/07/20, 5:55:24 PM] MBBS 2016 student: Is there a sinus arrest sir?
[17/07/20, 8:01:46 PM] Post residency PG 1: What is sinus arrest?
[17/07/20, 8:24:51 PM] MBBS 2016 student: SA node ceases for 3secs
[17/07/20, 8:27:09 PM] Post residency PG 1: How is it diagnosed in the EcG?
[17/07/20, 8:35:59 PM] MBBS 2016 student: Impulse is not generated within less than 2 sec
[17/07/20, 8:40:47 PM] Post residency PG 1: How will it appear in ECG? Can you share a Google Image?
[17/07/20, 8:56:51 PM] MBBS 2016 student: https://images.app.goo.gl/VW43qVuBg4vSZitN7
[17/07/20, 9:00:08 PM] Post residency PG 1: Do you think it's the same as our patient's Ecg?

MBBS 2016 student: yes sir
[17/07/20, 9:03:42 PM] Post residency PG 1: Tell me what is the most striking difference between our ECG and the one in Google Images. Maybe it would be better if you can select just one from Google Images and reshare

[17/07/20, 9:07:25 PM] MBBS 2016 student: P wave is absent before the qrs in lead 2
[17/07/20, 9:08:09 PM] MBBS 2016 student: In our case
[17/07/20, 9:09:38 PM] Post residency PG 1: 👍
So are their types of sinus arrests where that is possible?
What is the origin of our QRS there if not the sinus? Can it be junctional?
[17/07/20, 9:10:02 PM] MBBS 2016 student: Yes sir it can be junctional
[17/07/20, 9:11:37 PM] MBBS 2016 student: Origin of qrs could be av node or ventricle
[17/07/20, 9:12:18 PM] Post residency PG 1: Search and share what are the characteristics of junctional complexes and see if that fits our Ecg
[17/07/20, 9:12:37 PM] MBBS 2016 student: But what happened within few secs that ecg is so different

[17/07/20, 9:15:47 PM] MBBS 2016 student: In our case it might be the 1 st one with hidden p waves
[17/07/20, 10:54:07 PM] Post residency PG 1: 👍
[17/07/20, 10:55:40 PM] Post residency PG 1: Now check and share if junctional rhythm is seen in sick sinus syndrome


MBBS 2016 student:In the above journal it is mentioned that junctional rhythm is present in sick sinus syndrome
[18/07/20, 6:44:59 AM] Post residency PG 1: Excellent.
Post residency PG 1:The potassium sent during the time of taking the ECGs later revealed a serum potassium of 7 MEq
MBBS 2016 student 2:So, the reason behind the Sinus arrest and Irregularly Irregular Rhythm (A. Fib. ) could be attributed to Hyperkalemia (Characterized by Tall Tented T waves seen here ). Hyperkalemia is common in patients with CKD (as seen with our patient here). I also noticed a prolonged QTc which could indicate Hypocalcaemia or Hypomagnesemia along with the Hyperkalemia.
Post residency PG 1:Yes sinus arrest, junctional rhythm, a fib all as a result of hyperkalemia.
What is the underlying molecular mechanism of hyperkalemia producing this pathophysiology?
And immediatly after dialysis ,we saw these changes in monitor and anticipated hyperkalemia ,and started intervention.....within 15minutes after correction,rhythm reverted to normal .
[17/07/20, 5:36:09 PM] UG Student 3: Did he have Arrest because of hyperkalemia ?
[17/07/20, 5:36:23 PM]UG Student 3 :And after the dialysis, it got corrected
[17/07/20, 8:00:54 PM] PG post residency 1: What arrest?
[17/07/20, 8:03:43 PM] UG Student 3: Sir in the initial ECG, he had a prolonged bradycardia
[17/07/20, 8:03:49 PM] UG Student 3: Initially.
[17/07/20, 8:12:51 PM] UG Student 3: Sir in the initial ECG, the QRS complexes look narrow but in the 2nd ECG, they look broad
[17/07/20, 8:13:05 PM] UG Student 3: And rhythm is irregular
[17/07/20, 8:28:32 PM] PG post residency 1: So what was that due to? What kind of arrest? 🤔
[17/07/20, 8:29:37 PM] PG post residency 1: Are the QRS broad or just the S waves?
[17/07/20, 8:29:53 PM] PG post residency 1: In both. Why?
[17/07/20, 8:30:01 PM] UG Student 3: Yes sir it’s just the S waves.
[17/07/20, 8:30:33 PM] PG post residency 1 :Yes but why in just those two complexes?
[17/07/20, 8:30:59 PM] UG Student 3: Maybe Due to the hyperkalemia sir
[17/07/20, 8:31:16 PM] UG Student 3: He has capped T waves which are characteristic of Hyperkalemia
[17/07/20, 8:31:52 PM] PG post residency 1: We are not discussing the etiology but just the morphology of the EcG
[17/07/20, 8:33:04 PM] UG Student 3: Okay sir.
So I thought it could be Sick sinus syndrome.
[17/07/20, 8:33:11 PM] UG Student 3: Because of the initial ECG
[17/07/20, 8:34:44 PM] UG Student 3: Accessory pathways?
[17/07/20, 8:39:46 PM] PG post residency 1 :What features made you think of that?
[17/07/20, 11:02:39 PM] UG Student 3: Because there was bradycardia
[17/07/20, 11:04:04 PM] UG Student 3: In the initial ECG sir
[17/07/20, 11:37:00 PM] UG Student 3: Sinus bradycardia, sinus arrest too sir.
[18/07/20, 6:42:35 AM] PG post residency 1 :👍
[18/07/20, 6:45:42 AM] PG post residency 1 :Excellent. Please share the above ECG and the entire conversations above as an active learning blog post and share the link
[18/07/20, 6:46:03 AM] PG post residency 1 :Accessory pathways only for two complexes?
[18/07/20, 9:13:15 AM] UG Student 3: Sir I was thinking maybe it’s just a disturbance and they are not actually delta waves. Because there were none in the 1st ECG but in the 2nd one there are some. And they are only in the chest leads not in the limb leads sir.
So maybe it could be just a disturbance
[18/07/20, 9:22:28 AM] PG post residency 1 :So what is the electrical mechanism of production of delta waves? Accessory pathways are it's mechanical counterpart but what really happens at a electrophysiological level?
[18/07/20, 11:00:24 AM] UG Student 3: Since there is an accessory pathway, the impulse conducts through that and the AV node thereby we get a slurred QRS complex first followed by a normal QRS complex
[18/07/20, 11:00:34 AM] UG Student 3: That slurring is the delta wave
[18/07/20, 11:08:57 AM] PG post residency 1 : Is it possible that an accessory pathway can develop briefly for a few beats in terms of electrophysiology?
[18/07/20, 12:27:24 PM] UG Student 3: Yes sir it is possible in the case of WPW syndrome.
[18/07/20, 12:28:37 PM] UG Student 3: Because there are two pathways with different refractory periods sir.
[18/07/20, 2:03:11 PM] PG post residency 1: I meant can it happen without a mechanical accessory bypass tract just as an electrical phenomenon due to hyperkalemia?
[18/07/20, 2:55:14 PM] UG Student 3: Yes sir it can happen
[18/07/20, 4:11:52 PM] PG post residency 1: Share some literature around that?
[18/07/20, 11:35:40 PM] UG Student 3: “As potassium levels attain 10 mEq/L, the SA conduction no longer exists and passive junctional pacemakers supervene the electrical stimulation of the myocardium (accelerated junctional rhythm). This is followed by progressive widening of the QRS complex and the T-wave with obliteration of the ST-segment, so that the T-wave originates from the S-wave."
[18/07/20, 11:35:52 PM] UG Student 3:https://www.mdmag.com/medical-news/electrophysiologic_basis
[18/07/20, 11:37:41 PM] UG Student 3: Sir according to this article, I don’t think those are delta waves. Rather junctional rhythm with hidden p waves.
[19/07/20, 9:37:14 AM] PG post residency 1: 👍excellent.
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