ECG Diagnosis: Hyperkalemia
Published Online: March 1, 2013
Diagnosis of hyperkalemia is usually based on laboratory studies, although the electrocardiogram (ECG) may contain changes suggestive of hyperkalemia. Typical ECG findings in hyperkalemia progress from tall, “peaked” T waves and a shortened QT interval to lengthening PR interval and loss of P waves, and then to widening of the QRS complex culminating in a “sine wave” morphology and death if not treated.1–3 Treatment of life-threatening hyperkalemia focuses on blocking the effects on myocyte transmembrane potential and cardiac conduction, as well as decreasing extracellular potassium levels.3 Calcium (intravenous calcium chloride or gluconate) can effectively block the effect of extracellular potassium elevation on cardiac myocytes within minutes by restoring a more appropriate electrical gradient across the cellular membrane.2 Sodium bicarbonate, beta-2 adrenergic agonists, and the combination of glucose and insulin all drive potassium intracellularly and lower the extracellular serum potassium level.3 Finally, excessive body potassium can be removed with sodium polystyrene sulfonate (Kayexalate), whereas hemodialysis represents the definitive method to reduce serum potassium levels.2,3
Figure 1 12-lead ECG from an 82-year-old man with acute renal failure and hyperkalemia (serum potassium 8.6 mEq/dL).
Demonstrates a ventricular junctional escape rhythm (41 beats/min), with absence of P waves and peaked T waves.
Figure 2 12-lead ECG from same patient following treatment of hyperkalemia with intravenous calcium gluconate, insulin, glucose, normal saline, and oral kayexalate (serum potassium 6.2 mEq/dL).
Demonstrates a normal sinus rhythm (75 beats/min) with resolving peaked T waves.
References
1.
Slovis C, Jenkins R. ABC of clinical electrocardiography: Conditions not primarily affecting the heart. BMJ. 2002 6 1 324(7349):1320-3 DOI: https://doi.org/10.1136/bmj.324.7349.1320 Erratum in: BMJ 2002 Aug 3; 325(7358):259. BMJ 2007 May 26;334(7603). DOI: https://doi.org/10.1136/bmj.39219.615243.AD.
2.
Webster A, Brady W, Morris F. Recognising signs of danger: EKG changes resulting from an abnormal serum potassium concentration. Emerg Med J. 2002 1 19 19(1):74-7 DOI: https://doi.org/10.1136/emj.19.1.74.
3.
Diercks DB, Shumaik GM, Harrigan RA, Brady WJ, Chan TC. Electrocardiographic manifestations: electrolyte abnormalities. J Emerg Med. 2004 8 27(2):153-60 DOI: https://doi.org/10.1016/j.jemermed.2004.04.006.
Information & Authors
Information
Published In
Copyright
© 2013 The Permanente Journal.
Authors
Metrics & Citations
Metrics
Citations
Export citation
Select the format you want to export the citation of this publication.
Citing Literature
- Chin Lin, Chien-Chou Chen, Chin-Sheng Lin, Hung-Sheng Shang, Chia-Cheng Lee, Tom Chau, Shih-Hua Lin, Point-of-Care Potassium Measurement vs Artificial Intelligence–Enabled Electrocardiography for Hyperkalemia Detection, American Journal of Critical Care, 10.4037/ajcc2025597, 34, 1, (41-51), (2025).
- Humail Patel, Justin Lin, Lilly Hou, Lawrence Belletti, Unexpected Presentations of Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome: A Report of Two Cases, Cureus, 10.7759/cureus.58900, (2024).
- Evan S Sinnathamby, Kelly T Banh, William T Barham, Tyler D Hernandez, Audrey J De Witt, Danielle M Wenger, Vincent G Klapper, David McGregor, Antonella Paladini, Shahab Ahmadzadeh, Sahar Shekoohi, Alan D Kaye, Giustino Varrassi, Hyperkalemia: Pharmacotherapies and Clinical Considerations, Cureus, 10.7759/cureus.52994, (2024).
- Alexandr Ceasovschih, Victorița Șorodoc, Serghei Covantsev, Anastasia Balta, Jamol Uzokov, Sergio Kaiser, Abdallah Almaghraby, Cătălina Lionte, Cristian Stătescu, Radu Sascău, Viviana Onofrei, Raluca Ecaterina Haliga, Alexandra Stoica, Cristina Bologa, Ștefan Ailoaei, Yusuf Ziya Şener, Nicholas Kounis, Laurențiu Șorodoc, Electrocardiogram Features in Non-Cardiac Diseases: From Mechanisms to Practical Aspects, Journal of Multidisciplinary Healthcare, 10.2147/JMDH.S445549, Volume 17, (1695-1719), (2024).
- Amira Tej, Reham Hassan Mekky, María del Mar Contreras, Anouar Feriani, Meriam Tir, Boulbaba L'taief, Mohammed O. Alshaharni, Bilel Faidi, Kais Mnafgui, Zouhaier Abbes, Ezzeddine Saadaoui, Mohamed Ali Borgi, Nizar Tlili, Eucalyptus torquata seeds: Investigation of phytochemicals profile via LC-MS and its potential cardiopreventive capacity in rats, Food Bioscience, 10.1016/j.fbio.2024.103666, 59, (103666), (2024).
- Termboon Sangkabutra, Claudia Schneider, Steve F. Fraser, Simon Sostaric, Sandford L. Skinner, Michael J. McKenna, Differential effects of contracting muscle mass and relative exercise intensity on arterial plasma potassium concentration during and following incremental arm and leg cycling exercise, Advanced Exercise and Health Science, 10.1016/j.aehs.2024.02.001, 1, 2, (119-128), (2024).
- Taruna Chandok, Somin Lee, Nisha Ali, Amandeep Singh, Sandhya Cautha, Dynamic Changes of EKG by Severe Hyperkalemia: Transient Left Bundle Branch Block, Cureus, 10.7759/cureus.36124, (2023).
- Sairah Sharif, Jie Tang, Potassium Derangements: A Pathophysiological Review, Diagnostic Approach, and Clinical Management, Potassium in Human Health, 10.5772/intechopen.103016, (2022).
- Erdenebayar Urtnasan, Jung Hun Lee, Byungjin Moon, Hee Young Lee, Kyuhee Lee, Hyun Youk, Noninvasive Screening Tool for Hyperkalemia Using a Single-Lead Electrocardiogram and Deep Learning: Development and Usability Study, JMIR Medical Informatics, 10.2196/34724, 10, 6, (e34724), (2022).
- Liqaa A. Raffee, Khaled Z. Alawneh, Muhannad J. Ababneh, Heba H. Hijazi, Rabah M. Al abdi, Mahmoud M. Aboozour, Fadi A. Alghzawi, Abdel-Hameed Al-Mistarehi, Clinical and electrocardiogram presentations of patients with high serum potassium concentrations within emergency settings: a prospective study, International Journal of Emergency Medicine, 10.1186/s12245-022-00422-8, 15, 1, (2022).